Small molecule metabolites for the diagnosis of bacterial vaginosis and assessment of disease risk

ABSTRACT

The invention disclosed herein generally relates to methods and kits for diagnosing, assessing disease risk, treating, and preventing bacterial vaginosis (BV) and associated conditions. Additional embodiments include methods for developing metabolic profiles associated with increased disease risk, and developing new approaches to treat BV based on interrupting metabolic networks.

CROSS-REFERENCE TO RELATED APPLICATIONS

The present application is a U.S. National Stage entry under 35 U.S.C. § 371 of International Application No. PCT/US2016/027266, filed on Apr. 13, 2016, which claims priority to U.S. Provisional Application No. 62/146,867 filed on Apr. 13, 2015, each of which is incorporated by reference in its entirety.

GOVERNMENT SUPPORT

This invention was made with government support under A1061628 and HG005816 awarded by the National Institutes of Health. The government has certain rights in the invention.

FIELD OF THE INVENTION

The invention disclosed herein generally relates to methods and kits for diagnosing, assessing disease risk, treating, and preventing bacterial vaginosis (BV) and associated conditions. Additional embodiments include methods for developing metabolic profiles associated with increased disease risk, and developing new approaches to treat BV based on interrupting metabolic networks.

BACKGROUND

Bacterial vaginosis (BV) is a common but highly enigmatic condition that is associated with adverse outcomes for women and their neonates. BV is characterized by shifts in the vaginal microbiota from Lactobacillus dominant to a microbiota with diverse anaerobic bacteria. Small molecule metabolites in the vagina influence host physiology, affect microbial community composition, and impact risk of adverse health outcomes.

The composition of small molecule metabolites in the human vagina is largely shaped by bacterial metabolism of human derived nutrients. These bacterial metabolites may impact human cell function, inflammation, and disease susceptibility. However, few studies have comprehensively examined the associations between vaginal bacteria and metabolites, and no study has used quantitative PCR to link concentrations of fastidious vaginal bacteria to metabolite concentrations. Individual metabolites associated with BV status have been identified and shown to be useful markers of BV such as lactate (no BV) and succinate (BV) (1-7). However, there are hundreds of other compounds that have not been identified in vaginal fluid and linked to particular bacterial communities or clinical outcomes.

The composition of the human vaginal microbiota ranges from communities dominated by a limited of Lactobacillus species to complex communities of diverse anaerobes, most evident with the common condition BV (8-11). BV affects up to 29% of women in the United States (12), and has been associated with several adverse reproductive and health outcomes including elevated risks for acquisition of sexually transmitted infections (13-15), transmission of HIV to male sex partners (16), preterm birth (17), pelvic inflammatory disease (18), and cervicitis (19). The microbiota in BV is heterogeneous; different groups of women have vaginal microbiotas dominated with different bacteria such as BV-associated bacterium-1 (BVAB1), Leptotrichia/Sneathia species, Prevotella spp., Gardnerella vaginalis, or Lactobacillus iners, while others are colonized with diverse bacteria and no single dominant bacterium (11, 20). BV is diagnosed in clinical settings using Amsel criteria in which a set of four signs or symptoms are evaluated, with at least three required for a diagnosis of BV (21). Different bacteria are correlated with each of these four clinical criteria (11). Small molecule metabolites can affect at least three of these clinical criteria including vaginal discharge, pH, and amine odor. The diagnosis of BV can also be made using Gram stain interpretation of vaginal fluid smears with enumeration of bacterial morphotypes (22).

Polyamines such as putrescine and cadaverine are found in women with BV and contribute to the fishy amine odor in this condition (1, 23-25). These polyamines are likely produced from decarboxylation of amino acids mediated by bacteria (23). Chen et al. demonstrated that in vitro production of polyamines by mixed anaerobic vaginal bacteria was inhibited in the presence of metronidazole, suggesting a role for bacterial production of polyamines (26). Likewise, trimethylamine has a fishy odor, is found in women with BV, and is also thought to be a product of bacterial metabolism (27). These amines become volatile when pH is elevated, a property utilized in the clinical diagnosis of BV when employing the “whiff test” (4, 28, 29). The amine odor can also be noted in vivo with elevated pH during menses and after vaginal intercourse with men, as the pH of blood and semen are close to 7 leading to enhanced volatilization. It has been suggested that the amines are associated with increased vaginal transudation of fluid and squamous cell exfoliation, resulting in the thin homogeneous grayish-white discharge that is typically associated with BV (4).

Mass spectrometry (when coupled with chromatography) offers the opportunity to measure small molecule metabolites in the vagina, and assign identity to hundreds of compounds simultaneously. One recent study described the metabolite profiles in eight women with BV using this approach, and classified these women in to two groups based on their vaginal metabolite compositions (30). Additional insights into the functions of these bacterial consortia can be gained by linking bacterial community composition and concentrations of bacteria to metabolic signatures.

Current methods of diagnosing BV have numerous disadvantages. Most common methods of diagnosing BV and their disadvantages currently include: (1) Clinical settings: Amsel clinical criteria which include a set of four signs or symptoms of which at least three are required for a positive diagnosis. These include pH, a positive “whiff test,” greater than 20% clue cells (vaginal epithelial cells coated with bacteria) and a thin homogeneous discharge. This diagnostic procedure requires a trained clinician and a microscope is needed to evaluate clue cells; (2) Research settings: Vaginal fluid Gram stains and evaluation of the morphotypes based on the Nugent method or variations of the Ison & Hay method. The Nugent method is the gold standard in research settings, however, a highly trained microscopist is needed for evaluating the slides; (3) Detection of bacterial nucleic acids: Gen-Probe has developed a test targeting bacterial nucleic acids from bacteria that cause BV. Testing nucleic acids by PCR is typically expensive. Becton Dickinson has a BD Affirm VPIII system that can detect high levels of Gardnerella vaginalis DNA. However, G. vaginalis is not specific for the diagnosis of BV, as it is present in 70% of women without BV; (4) Detection of bacterial sialidase: OSOM BVBlue test that measures bacterial sialidases that are elevated in BV. While one study showed that the test was sensitive and specific (Bradshaw et al., 2005 JCM 43:1304-1308), other studies have not been able to demonstrate high sensitivity (Madhivanan et al., 2014 Infect Dis Obstet Gynecol Article ID 908313; Hillier https://clinicaltrials.gov/ct2/show/results/NCT00682851?sect=X01256.)

Thus there is a need for improved methods and kits for diagnosing, assessing disease risk, treating, and preventing BV and associated conditions.

SUMMARY

The present invention describes methods and kits for diagnosing, assessing disease risk, treating and preventing BV and associated conditions.

The method for diagnosing BV in a subject can include collecting a sample from the subject, assessing a small molecule metabolomic profile of a metabolomic signature by measuring levels of at least two indicative metabolites, and comparing the metabolomic profile with a diagnostic metabolomic profile of the signature. A substantial match between the metabolomic profile and the diagnostic metabolomic profile can be indicative of BV.

The method for monitoring disease progression of BV can include collecting a first sample from the subject; assessing a small molecule metabolomic profile of a metabolomic signature by measuring levels of at least two indicative metabolites; comparing the metabolomic profile with a diagnostic metabolomic profile of the signature; collecting a second sample from the subject; assessing a small molecule metabolomic profile of a metabolomic signature in the second sample by measuring levels of at least two indicative metabolites; and comparing the metabolomic profile with a diagnostic metabolomic profile of the signature. The disease progression can be based on substantial matches between the metabolomic profiles and the diagnostic metabolomic profiles. The second sample can be collected after a period of time from the first sample. The period of time can be at least three days.

The methods can include Chromatographic separation and/or mass spectroscopy. The substantial match can be at least 80%.

A kit for diagnosing BV in a subject in which the diagnosis is made with a test apparatus and include reagents for collecting a test sample from a subject; and reagents for measuring the profile of a metabolomics profile by measuring levels of indicative metabolites.

The sample can be vaginal fluid or Cervicovaginal lavage fluid (CVL).

The indicative metabolites can include two or more metabolites selected from the group listed in Table 1.

The indicative metabolites can include lipids, amino acids, nucleotides, co-factors, vitamins, carbohydrates, energy molecules and redox molecules.

The indicative metabolites can include amino acids such as 5-Aminovaleric Acid, Cadaverine, D-Leucic Acid, Glutaric Acid, Histamine, N-Acetylputrescine, Putrescine, Tryptamine, Tyramine, Anthranilate, Arginine, Asparagine, Aspartic Acid, Creatine, Cysteine, Cystine, Glycine, Histidine, iso-Leucine, Leucine, Lysine, Methionine, MethylSuccinate, Ornithine, Phenylalanine, Pipecolate, Reduced glutathione, Serine, Threonine, Tryptophan, Tyrosine, Xanthurenate. The indicative metabolites can include fatty acids such as 13-HODE, 12-HETE, Glycerol-3-P, Arachidonate, Carnitine. The indicative metabolites can include nucleotides such as Oxypurinol, Uracil, Adenosine, AMP, Hypoxanthine, and Urate. The indicative metabolites can include carbohydrates such as Glyceraldehyde, N-Acetylneuraminate, PEP, F16BP/F26BP/G16BP, Glucoronate, Glucose, Glutamic acid, Lactate, Oxalic Acid, and Sorbitol.

BRIEF DESCRIPTION OF THE DRAWINGS

Those of skill in the art will understand that the drawings, described below, are for illustrative purposes only. The drawings are not intended to limit the scope of the present teachings in any way.

FIG. 1 is a dendrogram showing associations of 30% of most variable metabolites with BV status, determined using Amsel and Nugent criteria. Clustering of the metabolites resulted in four groups (Clusters I-IV). The clustering algorithm was not informed by BV status. Study participant IDs are provided on the x-axis and metabolites are listed on the y-axis. The heat map depicts log-transformed concentrations of the most variable metabolites between the clusters. Values ranged from −6.956 to 4.818.

FIG. 2 depicts the association between metabolites and bacterial abundance. Hierarchically clustered Pearson correlation coefficients are displayed in a heat map to demonstrate associations of vaginal bacteria (relative abundance) detected using broad-range PCR and pyrosequencing (x-axis) with the abundance of 30% most variable metabolites (y-axis). Correlation values ranged from −0.7 to 0.84.

FIG. 3 depicts the association of specific vaginal bacteria with metabolites. Hierarchically clustered Pearson correlation coefficients are displayed in a heat map to demonstrate associations of key vaginal bacterial concentrations (x-axis) measured using taxon directed qPCR with the 30% most variable metabolites (y axis). Correlation values range from −0.71 to 0.85. Two sub-groups of BV associated bacteria were observed, and clustering patterns were similar to that noted in FIG. 2 using untargeted approach for bacterial community analysis. L. crispatus and L. jensenii exhibited correlation patterns that were similar and opposite to those by BV-associated bacteria.

FIG. 4 is a model depicting metabolites associated with individual clinical criteria used in BV diagnosis (21). Stars denote metabolites that were positively or negatively associated with BV status. BV status is indicated on the x-axis of box plots. The y axis of box plots represent scaled concentrations of metabolites. The lines in box plots represent the mean and whiskers denote 95% confidence intervals.

FIG. 5 depicts shifts in concentrations of key vaginal bacteria and metabolites with treatment for BV. Longitudinal data is presented for four study participants (19, 21, 23 & 25) who were cured of BV post treatment with metronidazole at the one month follow-up visit. Bacterial concentrations are displayed as 16S rRNA copies per swab on the y-axis of the XY-plots. Scaled metabolite concentrations (y-axis) of 14 metabolites associated with individual clinical criteria (from FIG. 4 & Table 3) have been classified as positively associated with BV and are higher in women BV and negatively associated with BV and are lower in women with BV. Y-axis scales are different for each subject reflecting differences in metabolite concentrations. All four participants had high concentrations of lactobacilli at their follow-up visits and increased concentrations of metabolites negatively associated with BV. Women with high concentrations of L. crispatus at follow-up had high concentrations of metabolites negatively associated with BV. Women with high concentrations of L. iners also showed increased concentrations of metabolites negatively associated with BV, but these shifts were not as dramatic as increases seen in women with L. crispatus dominant communities.

FIG. 6 is a model representing putative putrescine metabolism pathways in bacterial vaginosis. Box plots show selected metabolites that were detected in studies. BV status is indicated on the x-axis of box plots. The y-axis of box plots represent scaled concentrations of metabolites. The lines in box plots depict the mean, and whiskers denote 95% confidence intervals. Arginine typically serves as a precursor for the generation of polyamines putrescine, spermidine and spermine. Levels of putrescine were higher in BV, while levels of spermine were lower. Higher levels of succinate are a hallmark in BV. Recently, a novel putrescine utilization pathway has been discovered in Escherichia coli via γ-aminobutaraldehyde (GABA), resulting in succinate production. Higher levels of N acetylputrescine were observed in BV, which can also lead to GABA formation. Arrows next to metabolites indicate metabolites detected in the Examples, and show whether concentrations were higher or lower in women with BV.

FIG. 7 is a group of graphs depicting bacteria and metabolite concentrations in women with no changes in BV status. Limited longitudinal data are presented for 4 women who returned for follow-up visits 4 weeks after baseline sample collection per study protocol. BV status was evaluated by Amsel criteria and confirmed by Gram stain. Participants diagnosed with BV were treated with metronidazole. Bacterial concentrations are displayed as 16S rRNA copies per swab on the y-axis of the XY-plots. Scaled metabolite concentrations (y-axis) of 14 metabolites associated with individual clinical criteria (from FIG. 4 & Table 3) have been classified as positively associated with BV and negatively associated with BV. Y-axis scales are different for each subject reflecting differences in metabolite concentrations. (A) Study participants 4 and 7 did not have BV at either time point and had high concentrations of lactobacilli at both time points. High concentrations of metabolites negatively associated with BV were also noted at baseline and follow-up. (B) Study participants 12 and 28 had recurrent BV. In both participants, concentrations of metabolites associated with BV declined at the follow-up visit, but there was no associated increase in metabolites negatively associated with BV. This longitudinal analysis showed that stability of the microbiota was associated with few shifts in metabolites even after patients received antibiotic therapy.

FIG. 8 depicts an association between metabolites and bacterial abundance in the validation study. Hierarchically clustered Pearson correlation coefficients demonstrate associations of vaginal bacteria detected by broad-range PCR and pyrosequencing (x-axis) with metabolites (y-axis, 50% of the most variable metabolites based on inter-quartile range, and 12-HETE, arginine, ornithine, N acetylneuraminate and succinate). Correlation values ranged from −0.86 to −0.86.

FIG. 9 depicts metabolite profiles in women with intermediate Nugent scores. Non-metric multi dimensional scaling (MDS) plot summarizing metabolite profiles in women with and without BV classified by Nugent score. The MDS plot was created using non-metric multi-dimensional scaling of Euclidean distance between log-transformed metabolite concentrations, and represented in 2-dimensional space. Green dots denote women with Nugent scores 0-3, purple dots indicate women with intermediate scores 4-6 and red dots show women with scores 7-10. Women with intermediate Nugent scores have metabolite profiles ranging from those that are similar to women without BV (Nugent 0-3) to profiles which are more BV-like.

FIG. 10 depicts a comparison of metabolite concentrations in swab samples and CVL. A limited number of swab samples (n=8) were included in the validation study to determine the extent of dilution of metabolites in CVL samples. FIG. 10 summarizes the log 2 fold change of CVL relative to swab as a function of average log 2 abundance. Of the 101 metabolites detected using the NW-MRC platform, no metabolite was detected only in swab samples.

DETAILED DESCRIPTION OF THE INVENTION

Unless otherwise noted, terms are to be understood according to conventional usage by those of ordinary skill in the relevant art.

The present invention relates to methods and kits for diagnosing, assessing disease risk, treating and preventing BV and associated conditions.

In some embodiments, the invention relates to a method of diagnosing bacterial vaginosis (BV) in a subject including the steps of collecting a sample from the subject; assessing a small molecule metabolomic profile of a metabolomic signature by measuring levels of metabolites; comparing the metabolomic profile with a diagnostic metabolomic profile of the signature. In some embodiments, a substantial match between the metabolomic profile and the diagnostic metabolomic profile is indicative of bacterial vaginosis.

In some embodiments, the invention relates to a method of monitoring disease progression of BV in a subject including the steps of: collecting a first sample from the subject; assessing a small molecule metabolomic profile of a metabolomic signature by measuring levels of metabolites; comparing the metabolomic profile with a diagnostic metabolomic profile of the signature; wherein the disease progression is based at least in part upon a substantial match between the metabolomic profile and the diagnostic metabolomic profile; collecting a second sample from the subject; assessing a small molecule metabolomic profile of a metabolomic signature by measuring levels of metabolites; comparing the metabolomic profile with a diagnostic metabolomic profile of the signature; wherein the disease progression is based at least in part upon a substantial match between the metabolomic profile and the diagnostic metabolomic profile; wherein the disease progression is based at least in part upon a substantial match between the metabolomic profile and the diagnostic metabolomic profile; wherein the second sample is collected after a period of time from the first sample. The period of time can be 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 1 week, 2 weeks, 3 weeks, 1 month, 2 months 3 months, 4 months, 5 months or more.

In some embodiments, the invention relates to a kit for diagnosing BV in a subject in which the diagnosis is made with a test apparatus. The kit can include reagents for collecting a test sample from a subject; and reagents for measuring the profile of a metabolomics profile by measuring levels of metabolites.

In some embodiments, sample is vaginal fluid or Cervicovaginal lavage fluid (CVL).

In some embodiments, the metabolites include one or more metabolites selected from the group listed in Table 1. The method can include 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, or more metabolites from the group listed in Table 1.

In some embodiments, the metabolites include one or more of metabolites of lipids, amino acids, nucleotides, co-factors, vitamins, carbohydrates, energy molecules or redox molecules. In some embodiments, the metabolites include 1, 2, 3, 4, 5, 6, 7, 8, or all of lipids, amino acids, nucleotides, co-factors, vitamins, carbohydrates, energy molecules or redox molecules.

In some embodiments, the metabolites include one or more amino acids selected from 5-Aminovaleric Acid, Cadaverine, D-Leucic Acid, Glutaric Acid, Histamine, N-Acetylputrescine, Putrescine, Tryptamine, Tyramine, Anthranilate, Arginine, Asparagine, Aspartic Acid, Creatine, Cysteine, Cystine, Glycine, Histidine, iso-Leucine, Leucine, Lysine, Methionine, MethylSuccinate, Ornithine, Phenylalanine, Pipecolate, Reduced glutathione, Serine, Threonine, Tryptophan, Tyrosine, Xanthurenate, and the like. The method can include 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 or more of these amino acids.

In some embodiments, the metabolites can include one or more fatty acids selected from 13-HODE, 12-HETE, Glycerol-3-P, Arachidonate, Carnitine, and the like. The method can include 0, 1, 2, 3, 4, or all of these fatty acids.

In some embodiments, the metabolites can include nucleotides selected from Oxypurinol, Uracil, Adenosine, AMP, Hypoxanthine, Urate, and the like. The method can include 0, 1, 2, 3, 4, 5, or all of these nucleotides.

In some embodiments, the metabolites can include carbohydrates selected from Glyceraldehyde, N-Acetylneuraminate, PEP, F16BP/F26BP/G16BP, Glucoronate, Glucose, Glutamic acid, Lactate, Oxalic Acid, Sorbitol, and the like. The method can include 0, 1, 2, 3, 4, 5, 6, 7, 8, 9 or all of these carbohydrates.

In some embodiments, the a substantial match between the metabolomic profile and the diagnostic metabolomic profile is 50%, 60%, 70%, 80%, 90%, or more.

In some embodiments, the method comprises Chromatographic separation or mass spectroscopy, or both.

In some embodiments, the method includes pyrosequencing of the test sample. In some embodiments, the pyrosequencing targets the V3-V4 region of the 16S-rRNA gene.

TABLE 1 Heat map of statistically significant biochemicals profiled. For paired comparisons, asterisks indicate p≤0.05 ** indicate that the mean values are significantly higher for that comparison;* indicates values that are significantly lower). Italicized text indicates 0.05 < p < 0.10. Fold Change Statistical Welch's value Two- Welch's Sample Two-Sample PATH- SUPER t-Test t-Test WAY PATH- SUB BIOCHEMICAL PLAT- COMP Pos Pos/Neg Mean Values SORT WAY PATHWAY NAME FORM ID  Neg p-Value q-Value Neg  Pos  1 Amino Glycine, glycine GC/MS 11777 0.34* <0.001 0.0000 3.739741 1.263827 acid serine 2 and threonine sarcosine GC/MS 1516 4.44** <0.001 0.0000 0.427684 1.898044 metabolism (N-Methylglycine) 7 serine GC/MS 1648 0.20* <0.001 0.0002 6.580896 1.285634 9 N-acetylserine LC/MS 37076 0.41* <0.001 0.007 1.707820 0.697719 pos 16 threonine GC/MS 1284 0.23* <0.001 0.0002 5.900021 1.329807 17 N-acetylthreonine LC/MS 33939 0.19* <0.001 0.0000 3.111569 0.593361 neg 21 betaine LC/MS 3141 0.70* 0.0243 0.0119 1.202041 0.844976 pos 23 Alanine and alanine GC/MS 1126 0.80 0.1348 0.0520 1.891140 1.513845 24 aspartate beta-alanine GC/MS 55 1.62 0.2366 0.0857 0.810754 1.310248 26 metabolism N-acetylalanine LC/MS 1585 2.18** 0.0351 0.0165 0.915336 1.991908 neg 29 aspartate GC/MS 15996 0.22* 0.0013 0.0009 5.004044 1.116333 31 N-acetylaspartate (NAA) LC/MS 22185 6.21** <0.001 0.0000 0.405221 2.517588 pos 38 Glutamate glutamate LC/MS 57 0.44* 0.0072 0.0042 2.753214 1.204244 metabolism pos 42 glutamine LC/MS 53 0.56 0.1241 0.0485 1.649106 0.931688 pos 43 pyroglutamine* LC/MS 32672 0.75 0.0776 0.0329 1.288368 0.968558 pos 44 gamma-aminobutyrate GC/MS 1416 0.02* 0.0148 0.0077 81.695175 1.687678 (GABA) 45 N-acetylglutamate LC/MS 15720 3.72** <0.001 0.0000 0.556992 2.073273 pos 48 Histidine histidine LC/MS 59 0.02* <0.001 0.0003 4.207027 0.836916 metabolism neg 50 urocanate LC/MS 607 0.68 0.8376 0.2431 1.282119 0.833274 pos 53 histamine GC/MS 1574 0.72 0.7823 0.2313 2.076850 1.486302 60 Lysine cadaverine GC/MS 15308 27.38** <0.001 0.0000 0.146588 4.012971 66 metabolism lysine GC/MS 1301 0.08* <0.001 0.0000 11.290963 0.915742 67 2-aminoadipate GC/MS 6146 1.04 0.2273 0.0827 1.358665 1.407328 69 pipecolate LC/MS 1444 52.72** <0.001 0.0000 0.070170 3.699688 pos 74 N6-acetylysine LC/MS pos 36752 5.70** <0.001 0.0000 0.352662 2.009462 77 Phenylalanine phenylactate (PLA) LC/MS 22130 2.24 0.5252 0.1668 1.685189 3.772378 & lyrosine neg 78 metabolism phenylalanine LC/MS 64 0.15* <0.001 0.0000 4.537531 0.683247 pos 79.5 Isobar: 1- LC/MS 38763 5.76** <0.001 0.0000 4.475218 25.796219 phenylethanamine pos phenylethylamine 80 phenylacetate LC/MS 15958 3.72** <0.001 0.0001 0.175127 0.652184 neg 82 p-cresol sulfate LC/MS 36103 0.68 0.5443 0.1721 1.931141 1.309778 neg 90 tyrosine LC/MS 1299 0.11* <0.001 0.0000 6.775518 0.747969 pos 91 3-(4-hydroxyphenyl)- LC/MS 32197 0.54* 0.0103 0.0056 3.235635 1.732232 lactate neg 94 tyramine LC/MS 1603 21.24** <0.001 0.0000 0.333968 7.092416 pos 106 4-hydroxyphenylacetate GC/MS 541 51.37** <0.001 0.0000 0.049353 2.535028 111 N-acetylphenylalanine LC/MS 33950 2.24** 0.0222 0.0110 0.633846 1.421726 neg 115 phenylacetylglutamine LC/MS 35126 0.54 0.1103 0.0441 2.078089 1.129685 pos 118.5 3-(4-hydroxyphenyl)- GC/MS 39587 71.71** <0.001 0.0000 0.037424 2.683498 propionate 119 3-phenylpropionate LC/MS 15749 14.62** <0.001 0.0002 0.119842 1.752567 (hydrocinnamate) neg 121 phenol sulfate LC/MS 32553 0.80 0.7819 0.2313 0.985803 0.792313 neg 124 Tryptophan kynurenate LC/MS 1417 1.43** <0.001 0.0003 0.779062 1.115300 metabolism neg 125 kynurenine LC/MS 15140 0.46* 0.0058 0.0035 1.245910 0.571509 pos 126 tryptophan LC/MS 54 0.19* <0.001 0.0000 4.789226 0.915774 pos 127 indolelactate GC/MS 18349 0.38* 0.0198 0.0101 2.103397 0.792366 131 tryptophan betaine LC/MS 37097 1.07 0.9049 0.2548 1.250748 1.336430 pos 136 tryptamine LC/MS 6104 24.64** <0.001 0.0000 0.634729 15.642847 pos 147 3-indoxyl sulfate LC/MS 27672 0.89 0.8494 0.2453 0.997218 0.884641 neg 148 indolepropionate LC/MS 32405 1.54** 0.0174 0.0089 0.425099 0.653345 neg 149 Valine, 3-methyl-2-oxobutyrate LC/MS 21047 2.41** <0.001 0.0000 0.305080 0.734092 leucine neg 150 and 3-methyl-2-oxovalerate LC/MS 15676 2.30 <0.001 0.0000 0.440157 1.010772 isoleucine neg 156 metabolism alpha- LC/MS 22132 5.83** <0.001 0.0000 0.504073 2.939890 hydroxyisocaproate neg 157 isoleucine LC/MS 1125 0.52* <0.001 0.0002 2.412487 1.256762 pos 158 leucine LC/MS 60 0.31* <0.001 0.0000 3.289422 1.005091 pos 162 N-acetylleucine LC/MS 1587 3.24** <0.001 0.0003 0.500713 1.624179 pos 163 N-acetylvalline LC/MS 1591 223** <0.001 0.0005 0.432821 0.963793 pos 167 valine LC/MS 1649 0.77* 0.0282 0.0134 1.618634 1.239967 pos 170 4-methyl-2- LC/MS 22116 3.11** <0.001 0.000 0.356438 1.109900 oxopentanoate neg 175 alpha-hydroxyisovalerate GC/MS 33937 16.12** <0.001 0.0000 0.087300 1.407149 177 isobutyrylcamitine LC/MS 33441 0.21* <0.001 0.0000 2.624396 0.553982 pos 178 2-hydroxy-3- LC/MS 36746 18.48** <0.001 0.0000 0.088556 1.636135 methylvalerate neg 179 2-methyl- LC/MS 35431 0.16* <0.001 0.0000 2.672136 0.439636 butyroylcamitine pos 188 Cysteine, cysteine GC/MS 31453 0.03* <0.001 0.0000 15.954344 0.509295 191 methionine, cystein GC/MS 31454 0.11* <0.001 0.0002 0.698290 0.079583 193 SAM, taurine methionine sulfoxide LC/MS 18374 0.31* <0.001 0.0000 2.456314 0.750162 metabolism pos 194 N-formylmethionine LC/MS 2829 1.20 0.9900 0.2758 0.652447 0.784818 neg 195 hypolaurine GC/MS 590 0.59 0.1398 0.0533 1.801.513 1.061490 196 taurine GC/MS 2125 1.16 0.8229 0.2419 1.311479 1.517780 199 methionine LC/MS 1302 0.25* <0.001 0.0001 3.820236 0.945843 pos 201 N-acetylmethionine LC/MS 1589 0.99 0.0803 0.0338 1.822001 1.799556 neg 203 2-hydroxybutyrate GC/MS 21044 8.61** <0.001 0.0000 0.291261 2.508011 (AHB) 212 Urea cycle; dimethylarginine LC/MS 36808 1.33 0.1164 0.0461 0.946267 1.262746 arginine-, (SDMA + ADMA pos 213 proline-, arginine LC/MS 1638 0.10* <0.001 0.0001 4.932915 0.512710 metabolism pos 216 ornithine GC/MS 1493 0.05* <0.001 0.0002 19.529267 0.971406 217 urea GC/MS 1670 0.31* 0.0066 0.0039 3.618807 1.108288 218 proline LC/MS 1898 1.49 0.0915 0.0382 1.768739 2.631250 pos 219 5-aminovalerate GC/MS 18319 36.22** <0.001 0.0000 0.248177 8.988925 220 citrulline LC/MS 2132 3.28** <0.001 0.0003 0.652030 2.135567 pos 221 N-acetylomithine LC/MS 15630 1.88 0.1094 0.0440 1.173158 2.202987 pos 224 trans-4-hydroxyproline GC/MS 1366 0.81 0.8755 0.2492 1.710068 1.382874 232 Creatine creatine LC/MS 27718 0.38* <0.001 0.0000 1.899790 0.714386 metabolism pos 233 creatinine LC/MS 513 0.66* 0.0102 0.0056 1.415647 0.932472 pos 235 Butanoate 2-aminobutyrate GC/MS 1577 3.64* 0.0032 0.0021 0.842538 3.065685 metabolism 238 Polyamine 5-methylthioadenosine LC/MS 1419 1.49 0.0812 0.0341 0.856503 1.275299 metabolism (MTA) pos 239 putrescine GC/MS 1408 22.00** <0.001 0.0000 0.314180 6.910507 240 N-acetylputrescine LC/MS 37496 19.83** <0.001 0.0000 0.126190 2.502043 pos 241 agmatine GC/MS 15496 18.45** <0.001 0.0000 0.226448 4.178625 242 spermidine LC/MS 485 1.21 0.3210 0.1121 1.002315 1.217463 pos 244 spermine LC/MS 603 0.43* <0.001 0.0003 2.466098 1.058128 pos 251 Glutathione glutathione, reduced LC/MS 2127 0.03* <0.001 0.0000 7.943949 0.247406 metabolism (GSH) pos 253 5-oxoproline LC/MS 1494 0.51* <0.001 0.0001 1.812848 0.918718 pos 254 glutathione, oxidized LC/MS 38783 0.46* 0.0494 0.0222 2.418668 1.109746 (GSSG) pos 261 Peptide Dipeptide glycylvaline LC/MS 18357 0.41* 0.0035 0.0022 1.828693 0.748924 pos 262 glycylglycine GC/MS 21029 0.10* <0.001 0.0000 1.241861 0.129154 264 glycylproline LC/MS pos 22171 0.16* <0.001 0.0000 4.315719 0.695861 265 glycylisoleucine LC/MS pos 36659 0.43* 0.0018 0.0012 2.270640 0.984348 266 gtycylieucine LC/MS pos 34398 0.23* <0.001 0.0000 3.702514 0.869842 269 glycylphenylalanine LC/MS neg 33954 0.18* <0.001 0.0000 2.415152 0.429368 270 glycyltyrosine LC/MS neg 33958 0.36* 0.0023 0.0015 1.309452 0.474025 272 alanylalanine LC/MS neg 15129 0.55* 0.0212 0.0108 1.844075 1.023070 273 alanylthreonine LC/MS neg 37085 0.26* 0.0016 0.0010 1.516159 0.388090 274 alanylvaline LC/MS pos 37084 0.27* 0.0026 0.0017 3.456289 0.921019 278 alanylleucine LC/MS pos 37093 0.12* <0.001 0.0000 5.516745 0.645927 279 alanylarginine LC/MS neg 37096 0.34* 0.0077 0.0044 1.095681 0.374877 281 alanylglutamate LC/MS pos 37064 0.16* <0.001 0.0000 3.480754 0.571405 283 alanylisoleucine LC/MS pos 37118 0.74 0.1699 0.0636 1.171897 0.871067 283.5 alanylphenylalanine LC/MS pos 38679 0.14* <0.001 0.0000 4.253526 0.599824 285 alanyltyrosine LC/MS neg 37098 0.20* <0.001 0.0001 1.565923 0.319435 286 aspartylphenylalanine LC/MS pos 22175 0.36* <0.001 0.0005 1.470863 0.526500 286.5 aspartate-glutamate LC/MS neg 37461 0.30* <0.001 0.0002 1.467490 0.439940 287 alpha-glutamylglutamate LC/MS pos 22166 0.30* <0.001 0.0003 2.474494 0.739946 289 prolylleucine LC/MS neg 31914 0.77* 0.0247 0.0121 0.599613 0.463184 291 isoleucylisoleucine LC/MS pos 36761 0.64* 0.0280 0.0134 1.522233 0.976674 292 isoleucylleucine LC/MS pos 36760 0.67 0.1117 0.0444 1.572229 1.055765 295 leucylleucine LC/MS neg 36756 0.32 0.1026 0.0419 1.752017 0.552354 299 threonylphenylalanine LC/MS pos 31530 0.12* <0.001 0.0000 6.378384 0.783527 300 phenylalanylphenyl- LC/MS pos 38150 0.60 0.1004 0.0412 1.023343 0.612418 alanine 303 pyroglutamylvaline LC/MS neg 32394 0.42* 0.0034 0.0021 1.198512 0.497466 304 valinylglutamate LC/MS pos 32454 0.18* <0.001 0.0000 4.490319 0.795339 305 Isobar: glycylglutamate; LC/MS neg 34466 0.69* 0.0094 0.0053 1.373884 0.951120 glutamylglycine 366 Carbo- Aminosugars glucosamine GC/MS 18534 0.28* 0.0059 0.0035 1.108914 0.307987 372 hydrate metabolism erythronate* GC/MS 33477 0.72 0.3424 0.1180 1.013308 0.732922 374 N-acetylneuraminate LC/MS 32377 3.14** <0.001 0.0002 0.685260 2.150771 pos 379 fucose GC/MS 15821 1.62 0.0686 0.0295 1.442967 2.342404 389 Fructose, fructose GC/MS 31266 0.28* 0.0012 0.0008 1.756132 0.493023 391 mannose, galactose GC/MS 12055 5.63** <0.001 0.0004 0.318466 1.791958 397 galactose, maltose GC/MS 15806 0.46 0.7206 0.2164 6.579565 3.020671 398 starch, mannitol GC/MS 15335 0.02* 0.0010 0.0007 5.584213 0.114066 410 and sucrose sorbitol GC/MS 15053 0.70 0.0552 0.0241 0.535369 0.372560 417 metabolism maltotriose GC/MS 15877 0.23* 0.0095 0.0053 8.598705 2.015523 423 maltotetraose LC/MS 15910 0.28* 0.0016 0.0011 11.307067 3.204442 neg 425 maltopentaose LC/MS neg 35163 0.08* <0.001 0.0000 2.031463 0.164349 426 maltohexaose LC/MS neg 35170 0.12* <0.001 0.0001 1.779392 0.221209 430 Glycolysis, 1,5-anhydroglucitol GC/MS 20675 0.15* <0.001 0.0000 2.539897 0.376257 gluconeo- (1.5-AG) 432 genesis, glycerate GC/MS 1572 0.24* 0.0129 0.0068 3.611720 0.867426 434 pyruvate glucose-6-phosphate GC/MS 31260 2.74 0.8379 0.2431 0.699393 1.913208 metabolism (G6P) 436 glucose GC/MS 20488 1.30 0.4973 0.1586 2.138502 2.781033 442 Isobar fructose LC/MS 36984 0.18* <0.001 0.0000 2.519516 0.441328 1,6-diphosphate, neg glucose 1,6-diphosphate 450 pyruvate GC/MS 599 0.53 0.0996 0.0411 2.309850 1.228426 451 lactate GC/MS 527 0.13* <0.001 0.0000 5.553953 0.749216 462 Nucleotide ribitol GC/MS 15772 0.42* 0.0220 0.0110 0.981060 0.414604 463 sugars, threitol GC/MS 35854 5.38** <0.001 0.0000 0.194599 1.047048 466 pentose gluconate GC/MS 587 0.11* <0.001 0.0002 2.464444 0.270641 468 metabolism ribose GC/MS 12080 1.02 0.1081 0.0437 2.115984 2.168290 473 ribulose GC/MS 35855 0.12* 0.0011 0.0007 1.047534 0.122005 477 UDP-glucuronate LC/MS neg 2763 0.341 <0.001 0.0002 1.681324 0.577494 479 xylitol GC/MS 4966 1.44 0.7366 0.2194 0.478526 0.687893 491 Energy Krebs cycle citrate GC/MS 1564 .18 0.0689 0.0295 7.980905 1.404370 499 Lipid tricarballytate LC/MS neg 15729 2.90** 0.0089 0.0050 0.964367 2.795634 501 succinate GC/MS 1437 11.68** <0.001 0.0000 0.356008 4.156583 504 fumarate GC/MS 1643 0.87 0.4414 0.1431 1.404028 1.226511 507 malale GC/MS 1303 0.50 0.9955 0.2761 2.411262 1.216911 511 Oxidative phosphate GC/MS 11438 0.79 0.4293 0.1410 1.974197 1.568821 phosphor- ylation 512.5 Essential linoleate (18:2n6) LC/MS 1105 0.64 0.2888 0.1027 2.503180 1.612596 fatty neg 516 acid linolenate [alpha or LC/MS 34035 0.34 0.0777 0.0329 3.130635 1.065817 gamma; (18:3n3 or 6)] neg 517 dihomo-linolenate LC/MS 35718 0.44* 0.0012 0.0008 2.434987 1.078852 (20:3n3 or n6) neg 519 docosapentaenoate LC/MS 32504 0.55* <0.001 0.0005 1.692179 0.931787 (n3 DPA; 22:5n3) neg 521 docosahexaenoate LC/MS 19323 0.54* 0.0231 0.0114 1.407097 0.758958 (DHA, 22*6n3) neg 528 Medium chain pelargonate (9*0) LC/MS 12035 1.28** 0.0437 0.0200 0.967598 1.240067 fatty acid neg 535 Long chain myristate (14:0) LC/MS 1365 1.66** <0.001 0.0001 0.796121 1.324662 fatty acid neg 536 myristoleate (14:1n5) LC/MS neg 32418 1.25** 0.0422 0.0196 1.045900 1.305066 537 pentadecanoate (15:0) LC/MS neg 1361 1.57** 0.0082 0.0047 0.838910 1.315387 538 palmitate (16:0) LC/MS neg 1336 0.78 0.6337 0.1956 1.357113 1.061208 539 palmitoleate (16:1n7) LC/MS neg 33447 1.43 0.1048 0.0426 1.205405 1.723318 541 margarate (17:0) LC/MS neg 1121 0.62* 0.0049 0.0030 1.807274 1.114219 542 10-heptadecenoate LC/MS neg 33971 1.03 0.6744 0.2057 1.522486 1.567355 (17:1n7) 543 stearate (18:0) GC/MS 1358 0.38* 0.0051 0.0030 2.870164 1.082576 545 oleate (18:1n9) GC/MS 1359 0.36* 0.0029 0.0019 3.131461 1.122614 547 cis-vaccenate (18:1n7) GC/MS 33970 0.53 0.0989 0.0410 1.308343 0.692943 556 arachidate (20:0) GC/MS 1118 0.54 0.1506 0.0570 1.215563 0.651867 559 eicosenoate LC/MS neg 33587 1.42 0.6726 0.2057 1.455978 2.066571 (20:1n9 or 11) 561 dihomo-linoleate LC/MS neg 17805 1.38 0.9759 0.2728 1.476627 2.035057 (20:2n6) 565 arachidonate (20:4n6) LC/MS neg 1110 0.60* 0.0075 0.0043 2.562764 1.549759 569 docosadienoate (22:2n6) LC/MS neg 32415 1.37 0.8702 0.2487 1.276007 1.749032 573 lignocerate (24:0) GC/MS 1364 0.98 0.9003 0.2545 0.958237 0.940437 589 Fatty acid, n-Butyl Oleate GC/MS 36802 0.64 0.0506 0.0223 0.854271 0.544793 ester 591 Fatty acid, 4-hydroxybutyrate GC/MS 34585 20.00** <0.001 0.0000 0.084776 1.695504 monohydroxy (GHB) 602 2-hydroxystearate LC/MS neg 17945 1.57 0.3032 0.1068 1.381444 2.167484 603 13-HODE LC/MS neg 37374 3.90** 0.0042 0.0026 1.448723 5.656509 604 2-hydroxypalmitate LC/MS neg 35675 1.24 0.8312 0.2430 2.094107 2.590470 610 Fatty acid, 2-hydroxyglutarate GC/MS 37253 12.02** <0.001 0.0000 0.573594 6.896975 616 dicarboxylate azelate (nonanedioate) LC/MS 18362 0.67 0.4340 0.1413 1.578876 1.061955 neg 621 undecanedioate LC/MS neg 35671 0.81* 0.0497 0.0222 1.094301 0.885314 622 3-carboxy-4-methyl-5- LC/MS 31787 0.86 0.3299 0.1147 0.440869 0.378743 propyl-2-furanpropanoate neg (CMPF) 632.5 Fatty acid, 13-methylmyristic acid LC/MS 38293 1.95** <0.001 0.0000 0.710272 1.385212 branched neg 632.65 methyl palmitate LC/MS 38768 1.23 0.1820 0.0678 0.966898 1.188506 (15 or 2) neg 632.7 17-methylstearate LC/MS neg 38296 1.22 0.5782 0.1806 1.227807 1.500760 672 Eicosanoid 12-HETE LC/MS neg 37536 7.05** <0.001 0.0002 0.796090 5.614170 678 Endocanna- oleic ethanolamide LC/MS 38102 4.72** <0.001 0.0000 0.364114 1.811836 binoid neg 679 palmitoyl ethanolamide LC/MS neg 38165 4.97** <0.001 0.0000 0.470637 2.337596 683 Fatty acid propionylcamitine LC/MS 32452 0.24* <0.001 0.0000 2.834756 0.690499 metabolism pos 685 (also BCAA butyrylcamitine LC/MS 32412 0.34* <0.001 0.0000 2.199301 0.738763 metabolism) pos 691 Camitine deoxycamitine LC/MS 36747 22.972 <0.001 0.0000 0.124527 2.860155 metabolism pos 692 camitine LC/MS pos 15500 0.32* <0.001 0.0000 2.285080 0.720942 693 3-dehydrocamitine* LC/MS pos 32654 1.07 0.9085 0.2549 1.056017 1.133051 694 acetylcamitine LC/MS pos 32198 0.20* <0.001 0.0000 3.840583 0.784791 746 Glycerolipid ethanolamine GC/MS 34285 1.59 0.0504 0.0223 1.337565 2.130038 747 metabolism phosphoethanolamine GC/MS 12102 0.70 0.2959 0.1047 1.231679 0.856039 750 glycerol GC/MS 15122 0.44* 0.0462 0.0209 2.884838 1.279821 752 glycerol 3-phosphate GC/MS 15365 0.25* <0.001 0.0001 3.593932 0.881919 (G3P) 753 glycerophosphoryl- LC/MS pos 15990 0.18* <0.001 0.0000 7.439241 1.342709 choline (GPC) 760 Inositol myo-inositol GC/MS 19934 0.31* <0.001 0.0001 3.091537 0.969853 767 metabolism scyllo-inositol GC/MS 32379 0.49* 0.0108 0.0058 1.564517 0.762610 771 Ketone 1,2-propanediol GC/MS 38002 0.01 0.1276 0.0495 81.309337 1.067614 bodies 778 Lysolipid 2-palmitoleoylglycero- LC/MS 36619 0.53* 0.0037 0.0023 1.407027 0.744857 phosphoethanolamine* neg 780 1-stearoylglycerophos- LC/MS 34416 0.20* <0.001 0.0000 2.538105 0.507276 phoethanolamine neg 781 1-oleoylglycerophos- LC/MS 35628 0.591 0.0444 0.0201 1.906482 1.123846 phoethanolamine neg 782 2-oleoylglycerophos- LC/MS 35687 0.59 0.0515 0.0226 1.788931 1.054957 phoethanolamine* neg 783 1-linoleoylglycerophos- LC/MS 32635 0.57* 0.0276 0.0134 1.609657 0.920543 phoethanolamine* neg 784 2-linoleoylglycerophos- LC/MS 36593 0.47* <0.001 0.0001 1.606901 0.759890 phoethanolamine* neg 785 1-arachidonoylglycero- LC/MS 35186 0.56* 0.0114 0.0061 1.424438 0.795836 phosphoethanolamine* neg 786 2-arachidonoylglycero- LC/MS 32815 0.47* 0.0020 0.0013 1.349214 0.628647 phosphoethanolamine* neg 794 1-palmitoylglycero- LC/MS 33955 0.25* <0.001 0.0000 1.663882 0.411784 phosphocholine neg 799 1-stearoylglycerophos- LC/MS 33961 1.26 0.1396 0.0533 1.067878 1.345730 choline pos 802 2-oleoylglycerophos- LC/MS 35254 0.80 0.4231 0.1401 0.836825 0.673232 phochotine* pos 824 1-oleoylglycero- LC/MS 19260 0.93 0.3897 0.1319 1.893220 1.758314 phosphoserine neg 825.5 1-palmitoylplasmenyl- LC/MS 39270 0.36* <0.001 0.0003 2.917835 1.051735 ethanolamine* neg 833 Monoacyl- 1-stearoylglycerol GC/MS 21188 0.30* 0.0116 0.0061 1.079715 0.323913 glycerol (1-monostearin) 853 Sphingolipid sphinganine LC/MS pos 17769 0.98 0.6974 0.2110 2.095458 2.044173 855 sphingosine LC/MS pos 17747 1.02 0.1177 0.0464 2.767111 2.823340 864 palmitoyl sphingomyelin GC/MS 37506 0.85 0.3346 0.1158 1.625145 1.387937 879 Sterol/Steroid lathosterol GC/MS 33488 0.73 0.2682 0.0958 0.889059 0.645631 881 cholesterol GC/MS 63 0.76 0.2047 0.0752 1.697102 1.283848 883 dihydrocholesterol GC/MS 21131 2.78 0.3959 0.1331 0.822348 2.286362 891 dehydroisoandrosterone LC/MS neg 32425 0.98 0.6553 0.2015 0.620480 0.607584 sulfate (DHEA-S) 895 androsterone sulfate LC/MS neg 31591 1.09 0.5726 0.1796 0.539983 0.587072 935 4-androsten-3beta, LC/MS neg 37202 1.04 0.5474 0.1724 0.690855 0.718376 17beta-diol disulfate 1* 947 Nucleo- Purine xanthine GC/MS 3147 1.91 0.4941 0.1582 1.005427 1.916714 950 tide metabolism, hypoxanthine LC/MS 3127 0.37* <0.001 0.0003 3.114551 1.147087 951 (hypo)- neg xanthine/ inosine LC/MS 1123 0.071 <0.001 0.0000 1.748493 0.119613 inosine neg containing 955 Purine adenine LC/MS pos 554 0.70 0.0572 0.0248 1.459897 1.021916 956 metabolism adenosine LC/MS pos 555 0.33* 0.0132 0.0069 2.679957 0.894570 964 adenine adenosine 5′-monophos- LC/MS 32342 0.36* <0.001 0.0000 1.631900 0.588981 containing phate (AMP) pos 973 Purine guanine LC/MS 32352 0.40 0.2234 0.0817 3.619263 1.459953 metabolism. pos 976 guanine N2,N2-dimethylguanine LC/MS 37081 1.66** 0.0428 0.0198 0.790915 1.311851 containing pos 977 guanosine LC/MS pos 1573 0.31* 0.0044 0.0027 2.315595 0.723458 988 2′-O-methylguanosine LC/MS pos 36811 1.611 0.0362 0.0169 0.429850 0.691926 994 Purine urate LC/MS 1604 0.53* 0.0097 0.0053 1.241189 0.657312 metabolism, neg urate metabolism 1016 Pyrimidine thymine GC/MS 604 18.13** <0.001 0.0000 0.177007 3.209986 meta- bolism, thymine containing 1021 Pyrimidine 3-aminoisobutyrate GC/MS 1566 1.24 0.4286 0.1410 1.024298 1.269410 metabolism, thymine containing; Valine leucine and isoleucine metabolism/ 1022 Pyrimidine uracil GC/MS 605 0.62 0.1577 0.0594 2.927632 1.811774 1024 metabolism, uridine LC/MS 606 0.36* <0.001 0.0000 2.435443 0.880983 uracil neg 1025 containing pseudouridine LC/MS 33442 0.26* <0.001 0.0000 2.247591 0.580166 neg 1030.2 uridine monophosphate LC/MS 39879 0.81 0.1877 0.0696 0.955846 0.778221 (5′or 3′) pos 1040 Co- Ascorbate and ascorbate (Vitamin C) GC/MS 1640 0.01* <0.001 0.0002 11.476273 0.106009 1041 factors aldarate dehydroascorbate GC/MS 1659 0.53* 0.0431 0.0198 0.402364 0.215056 and metabolism 1055 vita- Hemoglobin heme* LC/MS 32593 0.32 0.4722 0.1518 4.510335 1.437990 mins and pos porphyrin 1063 Nicotinate nicotinamide LC/MS 594 0.30* <0.001 0.0002 2.563745 0.756635 and pos 1066 nicotinamide nicotinamide adenine LC/MS 5278 0.20* <0.001 0.0000 1.328450 0.268022 metabolism pos dinucleotide (NAD+) 1074 adenosine 5′diphospho- LC/MS 558 0.40* 0.0220 0.0110 1.648350 0.667043 ribose neg 1077 nicotoate LC/MS pos 1504 4.87** <0.001 0.0000 0.439218 2.139249 1085 Pantothenate pantothenate LC/MS 1508 1.04 0.3467 0.1189 1.248344 1.302237 and CoA pos 1088 metabolism 3′-dephosphocoenzyme LC/MS 18289 1.65** 0.0048 0.0029 0.305462 0.505276 A neg 1098 Riboflavin flavin adenine LC/MS 2134 2.05** <0.001 0.0001 0.565367 1.159047 metabolism dinucleotide (FAD) neg 1099 riboflavin (Vitamin B2) LC/MS pos 1827 1.79 0.1402 0.0533 0.628271 1.124005 1105 Tocopherol alpha-tocopherol GC/MS 1561 0.76* 0.0302 0.0143 0.560465 0.428338 metabolism 1117 Vitamin B5 pyridoxate LC/MS 31555 1.07 0.7353 0.2194 0.989351 1.058418 metabolism neg 1123 Xeno- Benzoate hippurate LC/MS 15753 0.08* 0.0105 0.0057 5.395996 0.453304 biotics metabolism neg 1126.5 3-hydroxyhippurate LC/MS neg 39600 0.33* 0.0282 0.0134 1.316128 0.435932 1127 4-hydroxyhippurate LC/MS neg 35527 1.08 0.8552 0.2453 0.790986 0.855582 1134 catechol sulfate LC/MS neg 35320 0.46 0.3141 0.1102 1.497728 0.687864 1157 Chemical glycerol 2-phosphate GC/MS 27728 0.18* <0.001 0.0002 1.215266 0.221673 1161 heptaethylene glycol LC/MS pos 38154 0.05 0.6818 0.2071 92.519657 4.360554 1162 hexaethylene glycol LC/MS pos 38133 0.07 0.3874 0.1317 20.503810 1.421641 1163 octaethylene glycol LC/MS pos 38155 0.05 0.3993 0.1331 107.214971 5.896527 1164 pentaethylene glycol LC/MS pos 38158 0.56 0.1946 0.0719 2.046873 1.150927 1180 2-pyrrolidinone GC/MS 31675 0.34 0.1244 0.0485 1.378630 0.466938 1216 Drug 4-acetaminophen sulfate LC/MS neg 37475 0.26 0.4002 0.1331 0.699167 0.182977 1217 4-acetamidophenol LC/MS pos 12032 0.86 0.8519 0.2453 0.426936 0.366874 1218 p-acetamidophenylglu- LC/MS neg 33423 0.11 0.3983 0.1331 2.333262 0.260924 curonide 1219 2-hydroxyacetamino LC/MS neg 33173 0.50 0.2670 0.0958 0.553826 0.279180 phen sulfate* 1220 2-methoxyacetamino LC/MS neg 33178 0.91 0.5959 0.1847 0.455487 0.413317 phen sulfate* 1221 3-(cystein-S-yl) LC/MS pos 34365 0.61 0.4318 0.1412 0.753281 0.459078 acetaminophen* 1268.6 benzoylecgonine LC/MS pos 39678 0.64 0.9982 0.2761 0.899112 0.578359 1281 Food saccharin LC/MD 21151 0.84 0.4548 0.1468 0.387694 0.327339 component/ neg 1341 Plant stachydrine LC/MS pos 34384 1.07 0.8783 0.2492 1.455998 1.561888 1343 Xanthine caffeine LC/MS 569 0.94 0.5837 0.1816 1.283809 1.211907 metabolism pos 1344 paraxanthine LC/MS pos 18254 1.44 0.2391 0.0862 0.665644 0.960747 1345 theobromine LC/MS pos 18392 1.18 0.3540 0.1209 0.799624 0.940328 1349 1,7-dimethylurate LC/MS neg 34400 0.96 0.8246 0.2419 0.865293 0.832235 1360 Sugar, sugar erythritol GC/MS 20699 0.94 0.7059 0.2128 0.963717 0.901261 substitute, starch BIOCHEMICAL NAME CAS PUBCHEM KEGG HMDB RP MASS glycine 56-40-6; 5,257,127,750 C00037 HMDB00123 1166 101.9 sarcosine (N-Methylglycine) 107-97-1; 10,887,311,726 C00213 HMDB00271 1182.9 116 serine 56-45-1; 59,516,857,581 C00065 HMDB03406 1389.1 204 N-acetylserine 97-14-3; 65249 HMDB02931 1012 148 threonine 72-19-5; 69,710,196,288 C00188 HMDB00167 1412.3 218.1 N-acetylthreonine 4651717 C01118 846 160.1 betaine 107-43-7; 247 HMDB00043 721 118.2 alanine 56-41-7; 59,507,311,724 C00041 HMDB00161 1147.6 115.9 beta-alanine 56-41-7; 2,394,755,801 C00099 HMDB00056 1451.8 174 107-95-9; N-acetylalanine 97-69-8; 88064 C02847 HMDB00766 882 130.1 aspartate 56-84-8; 5960 C00049 HMDB00191 1529.7 232 N-acetylaspartate (NAA) 997-55-7;997- 65065 C01042 HMDB00812 1222 176.1 55-7; glutamate 56-86-0; 611 C00025 HMDB03339 700 148.1 glutamine 56-85-9; 69,920.865,961 C00064 HMDB00641 684 147.2 pyroglutamine* 134508 764 129.2 gamma-aminobutyrate (GABA) 56-12-2; 6,992,099,119 C00334 HMDB00112 1539.7 304.1 N-acetylglutamate 5817-08-3; 1549099 C00624 HMDB01138 1492 190.1 histidine 5934-29-2; 7,733,651,426 C00135 HMDB00177 757 154.1 urocanate 104-98-3; 736715 C00785 HMDB00301 1164 139.1 histamine 51-45-6; 774 C00388 HMDB00870 1809.7 174.1 cadaverine 462-94-2;1476-39-7; C01672 HMDB02322 1780.4 174 lysine 56-87-1; 5962 C00047 HMDB00182 1836.7 317.2 2-aminoadipate 542-32- 469 C00956 HMDB00510 16865 260.1 5;1118-90-7; pipecolate 4043-87-2; 849 C00408 HMDB00070 1120 130.1 N6-acetyllysine 692-04-6; 699,197,892,832 C02727 HMDB00206 1134 189.1 phenyllactate (PLA) 828-01-3; 3848 C05607 HMDB00779 2237 165.1 phenylalanine 63-91-2; 69,256,656,140 C00079 HMDB00159 2056 166.1 Isobar: 1-phenylethanamine, phenylethy C02455, HMDB02017 2114.7 122.1 amine C05332 HMDB12275 phenylacetate 103-82-2; C07086 HMDB00209 2127 135.1 p-cresol sulfate 3233-57-7; 4615422 C01468 2896 187.1 tyrosine 60-18-4; 60,576,942,100 C00082 HMDB00158 1516 182.1 3-(4-hydroxyphenyl)lactate 6482-98-0; 9378 C03672 HMDB00755 1395 181.1 tyramine 60-19-5; 5610 C00483 HMDB00306 1503 138.1 4-hydroxyphenylacetate 156-38-7; 4693933 C00642 HMDB00020 1630.6 179 N-acetylphenylalanine 2018-61-3; 74839 C03519 HMDB00512 2590 206.2 phenylacetylglutamine 28047-15-6; 306137 C05597 HMDB06344 2868 265.2 3-(4-hydroxyphenyl)propionate 501-97-3; 10394 C01744 HMDB02199 1727.9 179.1 3-phenylpropionate (hydrocinnamate) 501-52-0; C05629 HMDB00764 2830 149.1 phenol sulfate 937-34-8; 74426 C02180 2199 173.1 kynurenate 492-27-3; 3845 C01717 HMDB00715 2243 188.1 kynurenine 2922-83-0; 1,611,666,971,029 C00328 HMDB00684 1902 209.1 tryptophan 73-22-3; 69,235,166,305 C00078 HMDB00929 2445 205.1 indolelactate 832-97-3; 92904 C02043 HMDB00671 1964.9 202 tryptophan betaine 20671-76-5; 442106 C09213 2464 247.1 tryptamine 61-54-1; 1150 C00398 HMDB00303 2323 161.1 3-indoxyl sulfate 2642-37-7; 10258 HMDB00682 2258 212 indolepropionate 830-96-6; 3744 HMDB02302 2795 188.2 3-methyl-2-oxobutyrate 3715-29-5; 49 C00141 HMDB00019 1489 115.1 3-methyl-2-oxovalerate 51829-07-3; 47 C00671 HMDB03736 2106 129.2 alpha-hydroxyisocaproate 10303-64-7; 83697 C03264 HMDB00746 1854 131.2 isoleucine 73-32-5; 791 C00407 HMDB00172 1614 132.1 leucine 61-90-5; 70,457,986,106 C00123 HMDB00687 1674 132.2 N-acetylleucine 1188-21-2; 70912 C02710 HMDB11756 3444 174.1 N-acetylvaline 96-81-1; 66789 HMDB11757 2654 160.1 valine 72-18-4; 69,710,186,287 C00183 HMDB00883 1040 118.1 4-methyl-2-oxopentanoate 816-66-0; 70 C00233 HMDB00695 2200 129.2 alpha-hydroxyisovalerate 600-37-3; 99823 HMDB00407 1208 145.1 isobutyrylcamitine 25518-49-4; 1941 232.2 2-hydroxy-3-methylvalerate 488-15-3; 164623 HMDB00317 1787 131.1 2-methylbutyroylcamitine 31023-25-3; 6426901 HMDB00378 2439 246.1 cysteine 52-90-4;56-89-3* 58,626,419,722 C00097 HMDB00574 1560.1 218 cystine 56-89-3; 595 C00491 HMDB00192 2015.3 218 methionine sulfoxide 3226-65-1; 1,589,801,548,907 C02989 HMDB02005 729 166.1 N-formylmethionine 4289-98-9; 439750 C03145 HMDB01015 1541 176.1 hypotaurine 300-84-5; 107812 C00519 HMDB00965 1598.5 188 taurine 107-35-7; 11,234,068,592 C00245 HMDB00251 16164 254.1 methionine 63-68-3; 69,920,876,137 C00073 HMDB00696 1252 150.1 N-acetylmethionine 65-82-7; 448580 C02712 HMDB11745 1805 190.1 2-hydroxybutyrate (AHB) 3347-90-8; 440864 C05984 HMDB00008 1169.4 130.9 dimethylarginine (SDMA + ADMA) 123831 C03626 HMDB01539. 812 203.2 HMDB03334 arginine 1119-34-2; 5,246,487,232 C00062 HMDB00517 650 175.2 ornithine 3184-13-2; 6262 C00077 HMDB03374 1763.8 141.9 urea 57-13-6; 117,616,150,869 C00086 HMDB00294 1223.9 171 proline 147-85-3; 1,457,426,971,047 C00148 HMDB00162 796 116.1 5-aminovalerate 660-88-8; 6,992,101,138 C00431 HMDB03355 1620.8 174 citrulline 372-75-8* 833 C00327 HMDB00904 715 176.1 N-acetylornithine 6205-08-9; 6,992,102,439,232 C00437 HMDB03357 875 175.2 trans-4-hydroxyproline 51-35-4; 58,106,971,053 C01157 HMDB00725 1537 140 creatine 57-00-1; 586 C00300 HMDB00064 758 132.1 creatinine 60-27-5; 588 C00791 HMDB00562 730 114.1 2-aminobutyrate 1492-24-6; 4,396,916,971,251 C02261 HMDB00650 1215.7 130 5-methylthioadenosine (MTA) 2457-80-9; 439176 C00170 HMDB01173 2427 298.1 putrescine 110-60-1; C00134 HMDB01414 1705.8 174 N-acetylputresdne 18233-70-0; 122356 C02714 HMDB02064 895 131.1 agmatine 2482-00-0; 199 C00179 HMDB01432 1528 174 spermidine 124-20-9; 1102 C00315 HMDB01257 533 146.2 spermine 71-44-3; 1103 C00750 HMDB01256 506 203.2 glutathione, reduced (GSH) 70-18-8; 124886 C00051 HMDB00125 1274 308.1 5-oxoproline 98-79-3; 7405 C01879 HMDB00267 1446 130.1 glutathione, oxidized (GSSG) 103239-24-3; 6,535,911,215,652 C00127 HMDB03337 1535 307.3 glycylvaline 1963-21-9; 27,248,076.994, 1572 175.1 979 glycylglycine 556-50-3* 154,889,711,163 C02037 HMDB11733 1757.9 174 glycylproline 704-15-4* 30,136,256,993, HMDB00721 1115 173.1 386 glycylisoleucine 19461-38-2; 2080 189.1 glycylleucine 869-19-2; 928,431,548,899 C02155 HMDB00759 2236 189.1 glycylphenylalanine 3321-03-7; 154,934,492,953 2193 221.2 glycyltyrosine 658-79-7; 928,296,994,980 1446 237.2 alanylalanine 1948-31-8; 54,603,626,992, C00993 HMDB03459 815 159.2 112 alanylthreonine 426318 827 189 alanylvaline 137276 1513 189 alanylleucine 259583 2150 203 alanylarginine 9964828 1079 244.1 alanylglutamate 656476 766 219 alanylisoleucine 4,173,585,246.008 2011 203.1 alanylphenylalanine 3061-90-3; 2080 2422 237.2 alanyltyrosine 5,723,194,099,800 1642 251 aspartylphenylalanine 13433-09-5; 93078 HMDB00706 2538 281.1 aspartate-glutamate 6157-06-8; 4130574 603 261.2 alpha-glutamylglutamate 3929-61-1; 439500 C01425 857 277.1 prolylleucine 52899-07-7; 4,441,097,082,009 2985 227.2 isoleucylisoleucine 42537-99-5; 2678 245.1 isoleucylleucine 26462-22-6; 11644431 2856 245.1 leucylleucine 3303-31-9; 768,076,992,072 C11332 3895 243.2 threonylphenylalanine 40.997,994.099, 2500 267.2 798 phenylalanylphenylalanine 2577-40-4; 69,930,906.993, 3317 313.2 089 pyroglutamylvaline 152416 1755 227.2 valinylglutamate 3062-07-5; 7009623 1346 247.1 Isobar: glycylglulamate; glutamylglycine 634 203.1 glucosamine 66-84-2; 441477 C00329 HMDB01514 1833 203 erythronate* 13752-84-6; 2781043 HMDB00613 1546.9 292.1 N-acetylneuraminate 131-48-6; C00270 HMDB00230 787 310 fucose 2438-80-4; 3034656 C00382 HMDB00174 1682.2 204 fructose 57-48-7; 5984 C00095 HMDB00660 1762.7 204 galactose 59-23-4; 3037556 C01582 HMDB00143 1793.8 203.9 maltose 6363-53-7; 439341 C00208 HMDB00163 2142.1 204.1 mannitol 69-65-8; 6251 C00392 HMDB00765 1839 319.1 sorbitol 6706-59-8; 107428 C00794 HMDB00247 1843 319.1 maltotriose 1109-28-0; 439586 C01835 HMDB01262 2419 204 maltotetraose 34612-38-9; 446495 C02052 HMDB01296 965 665.1 maltopentaose 34620-76-3; 3710145 C06218 HMDB12254 1100 827 maltohexaose 34620-77-4; 5288409 C01936 HMDB12253 1224 989 1,5-anhydroglucitol (1,5-AG) 154-58-5; C07326 HMDB02712 1788.7 217 glycerate 600-19-1; 752 C00258 HMDB00139 1360.7 189 glucose-6-phosphate (G6P) 103192-55-8; C00668 HMDB01401 2042.7 387.2 glucose 50-99-7; 79025 C00293 HMDB00122 1866.8 217.1 Isobar: fructose 1,6-diphosphate, 572 339 glucose 1,6-diphosphate pyruvate 127-17-3; 107735 C00022 HMDB00243 1130.6 217 lactate 79-33-4; 612 COO186 HMDB00190 1102.8 116.9 ribitol 488-81-3; C00474 HMDB00508 1692.4 217 threitol 2418-52-2; 169019 C16884 HMDB04136 1513 217.1 gluconate 527-07-1; 10690 C00257 HMDB00625 1879.4 333 ribose 50-69-1; 5311110 C00121 HMDB00283 1639.2 204 ribulose 488-84-6; 79021 C00309 HMDB00621, 1662 306.1 HMDB03371 UDP-glucuronate 28053-08-9;63700-19-6; 17473 C00167 HMDB00935 594 579.1 xylitol 87-99-0; 6912 C00379 HMDB00568 1677.6 307.2 citrate 77-92-9; 311 C00158 HMDB00094 1763.4 273.1 tricarballylate 99-14-9; 14925 592 175 succinate 110-15-6; 1110 C00042 HMDB00254 1348 247 fumarate 100-17-8; C00122 HMDB00134 1382.1 245 malate 6915-15-7; 525 C00149 HMDB00156 1502 233 phosphate 7664-38-2; 1061 C00009 HMDB01429 1307.7 298.9 linoleate (18:2n6) 60-33-3; 5280450 C01595 HMDB00673 5533 279.3 linolenate [alpha or gamma; (18:3n3 or 6)] C06427 HMDB01388 5450 277.3 dihomo-linolenate (20:3n3 or n6) 5312529 C03242 HMDB02925 5600 305.4 docosapentaenoate (n3 DPA; 22:5n3) 2234-74-4; C16513 HMDB01976 5574 329.4 docosahexaenoate (DHA; 22:6n3) 6217-54-5; 445580 C06429 HMDB02183 5518 327.3 pelargonate (9:0) 112-05-0* 5461016 C01601 HMDB00847 4847 157.2 myristate (14:0) 544-63-8* 11005 C06424 HMDB00806 5439 227.3 myristoleate (14:1n5) 544-64-9; 5281119 C08322 HMDB02000 5338 225.3 pentadecanoate (15:0) 1002-84-2; 13849 C16537 HMDB00826 5522 241.3 palmitate (16:0) 57-10-3; 985 C00249 HMDB00220 5619 255.3 palmitoleate (16:1n7) 373-49-9; 445638 C08362 HMDB03229 5477 253.3 margarate (17:0) 506-12-7; 10465 HMDB02259 5733 269.3 10-heptadecenoate (17:1 n7) 29743-97-3; 5312435 5558 267.3 stearate (18:0) 57-11-4; 5281 C01530 HMDB00827 1994.6 341.3 oleate (18:1n9) 112-80-1; 445639 C00712 HMDB00207 1984.4 339.2 cis-vaccenate (18:1n7) 693-72-1; 5282761 C08367 1987 339.3 arachidate (20:0) 506-30-9; 10467 C06425 HMDB02212 2071.2 369.3 eicosenoate (20:1 n9 or 11) HMDB02231 5955 309.4 dihomo-linoleate (20:2n6) 2091-39-6; 6439848 C16525 5722 307.3 arachidonate (20:4n6) 506-32-1; 444899 C00219 HMDB01043 5525 303.4 docosadienoate (22:2n6) 7370-49-2; 5282807 C16533 6017 335.4 lignocerate (24:0) 557-59-5; 11197 C08320 HMDB02003 2211 425.4 n-Butyl Oleate 142-77-8; 5354342 2045 265.3 4-hydroxybutyrate (GHB) 502-85-2; 10413 C00989 HMDB00710 1277 233.1 2-hydroxystearate 629-22-1; 69417 C03045 5705 299.4 13-HODE 29623-28-7; 6443013 C14762 HMDB04667 5251 295.3 2-hydroxypalmitate 764-67-0; 92836 5508 271.3 2-hydroxyglutarate 40951-21-1; 43 C02630 HMDB00606 1576 247 azelate (nonanedioate) 123-99-9; 2266 C08261 HMDB00784 1322 187.2 undecanedioate 1852-04-6; 15816 HMDB00888 2376 215.1 3-carboxy-4-methyl-5-propyl-2- 86879-39-2; 123979 2815 239.1 furanpropanoate (CMPF) 13-methylmyristic acid 2485-71-4; 151014 5498 241.3 methyl palmitate (15 or 2) 5698 269.4 17-methylstearate 2724-59-6; 3083779 5987 297.4 12-HETE 73837-14-6; HMDB06111 5295 319.3 oleic ethanolamide 11-58-0;111- 5283454 HMBD02088 6553 324.5 58-0; palmitoyl ethanolamide 4671 6416 298.4 propionylcamitine 17298-37-2; 107738 C03017 HMDB00824 1589 218.2 butyrylcamitine 25576-40-3; 213144 2007 232.2 deoxycamitine 6249-56-5; 725 C01181 HMDB01161 759 146.1 carnitine 461-05-2; 10917 702 162.2 3-dehydrocamitine* 10457-99-5; 6991982 C02636 HMDB12154 1020 160.2 acetylcamitine 5080-50-2; 7045767 C02571 HMDB00201 1203 204.2 ethanolamine 141-43-5; C00189 HMDB00149 1074 102 phosphoethanolamine 1071-23-4; 52,323,241,015 C00346 HMDB00224 1577.3 299.1 glycerol 56-81-5; 753 C00116 HMDB00131 1311 205 glycerol 3-phosphate (G3P) 29849-82-9; 754 C00093 HMDB00126 1719.7 357.1 glycerophosphorylcholine (GPC) 28319-77-9; 657272 C00670 HMDB00086 694 258.1 myo-inositol 87-89-8; C00137 HMDB00211 1924.9 217 scyllo-inositol 488-59-5; C06153 HMDB06088 1893.8 318.2 1,2-propanediol 57-55-6; C00717, HMDB01881 1041 117 C02912, C00583, C01506, C02917 2-palmitoleoylglycerophosphoethanolamine* 5611 450.3 1-stearoylglycerophosphoethanolamine 69747-55-3; 9547068 HMDB11130 6200 480.4 1-oleoylglycerophosphoethanolamine 9547071 HMDB11506 5928 478.3 2-oleoylglycerophosphoethanolamine* 5848 478.3 1-linoleoylglycerophosphoethanolamine* HMDB11507 5725 476.3 2-linoleoylglycerophosphoethanolamine* 5650 476.4 1-arachidonoylglycerophosphoethanolamine* HMDB11517 5731 500.3 2-arachidonoylglycerophosphoethanolamine* 5674 500.3 1-palmitoylglycerophosphocholine 17364-16-8; 86554 6046 570 1-stearoylglycerophosphocholine 19420-57-6; 497299 5844 524.4 2-oleoylglycerophosphocholine* 5640 522.4 1-oleoylglycerophosphoserine 9547099 5690 522.3 1-palmitoylplasmenylethanolamine* 6153 436.4 1-stearoylglycerol (1-monostearin) 123-94-4; 24699 D01947 2186.6 399.4 sphinganine 3102-56-5; 3126 C00836 HMDB00269 5175 302.3 sphingosine 123-78-4; 5353955 C00319 HMDB00252 5197 300.2 palmitoyl sphingomyelin 9939941 2524 311.3 lathosterol 80-99-9; 65728 C01189 HMDB01170 2337 458.5 cholesterol 57-88-5; 6432564 C00187 HMDB00067 2316.9 329.3 dihydrocholesterol 80-97-7; 6665 HMDB00908 2320.8 215.2 dehydroisoandrosterone sulfate (DHEA-S) 12594 C04555 HMDB01032 4771 367.2 androsterone sulfate 2479-86-9; C00523 HMDB02759 5011 369.2 4-androsten-3beta,17beta-diol disulfate 1* HMDB03818 3735 224.3 xanthine 69-89-6; 1188 C00385 HMDB00292 1889.9 353 hypoxanthine 68-94-0; 790 C00262 HMDB00157 1313 135.1 inosine 58-63-9; 1630 267.2 adenine 73-24-5; 190 C00147 HMDB00034 1003 136.1 adenosine 58-61-7; 60961 C00212 HMDB00050 1650 268.1 adenosine 5’-monophosphate (AMP) 149022-20-8; 15938965 C00020 HMDB00045 1210 348.1 guanine 73-40-5; 764 C00242 HMDB00132 1022 152.1 N2,N2-dimethylguanine 1445-15-4; 74047 1764 180 guanosine 118-00-3; 6802 C00387 HMDB00133 1676 284 2′-O-methylguanosine 2140-71-8; C04545 1926 298 urate 69-93-; C00366 HMDB00289 769 167.1 2;120K5305 thymine 65-71-4; 1135 C00178 HMDB00262 1429.1 255 3-aminoisobutyrate 10569-72-9; 64956 C05145 HMDB03911 1252.2 101.9 uracil 66-22-8; 1174 C00106 HMDB00300 1370.4 241 uridine 58-96-8; 6029 C00299 HMDB00296 1467 243.1 pseudouridine 1445-07-4; C02067 HMDB00767 1104 243.1 uridine monophosphate (5′ or 3′) 1079 325 ascorbate (Vitamin C) 134-03-2; C00072 HMDB00044 1850.1 332.1 dehydroascorbate 490-83-5; 835 C05422 HMDB01264 1800 245.1 heme* 14875-96-8* 4985 616.2 nicotinamide 98-92-0; 936 C00153 HMDB01406 1267 123.1 nicotinamide adenine dinucleotide 53-84-9; 1,089,765,158, C00003 HMDB00902 1370 664 925,280,000 (NAD+)adenosine 5′diphosphoribose 68414-18-6; 4475880 C00301 HMDB01178 964 558.1 nicotinate 59-67-6; 938 C00253 HMDB01488 1241 124.1 pantothenate 137-08-6; 6613 C00864 HMDB00210 2218 220.1 3'-dephosphocoenzyme A 3633-59-8; 444485 C00882 HMDB01373 2010 686.2 flavin adenine dinucleotide (FAD) 146-14-5;84366-81-4; 643975 C00016 HMDB01248 2413 784.1 riboflavin (Vitamin B2) 83-88-5; 493570 C00255 HMDB00244 3111 377.2 alpha-tocopherol 59-02-9; 14985 C02477 HMDB01893 2305.4 502.5 10191-41-0; pyridoxate 82-82-6; 6723 C00847 HMDB00017 2210 182.1 hippurate 495-69-2; 464 C01586 HMDB00714 2136 178.1 3-hydroxyhippurate 450268 HMDB06116 1670 194.1 4-hydroxyhippurate 2482-25-9; 151012 1439 194 catechol sulfate 3083879 C00090 1928 188.9 glycerol 2-phosphate 819-83-0; 2526 C02979, HMDB02520 1691.8 243 D01488 heptaethylene glycol 5617-32-3; 79718 2836 327.2 hexaethylene glycol 2615-15-8; 17472 2651 283.2 octaethylene glycol 5117-19-1; 78798 3054 371.3 pentaethylene glycol 4792-15-8; 62551 2471 239.2 2-pyrrolidinone 616-45-5; 12025 HMDB02039 1190.9 142 4-acetaminophen sulfate 10066-90- 83939 C06804 HMDB01859 1779 230.1 7;32113- 41-0; 4-acetamidophenol 103-90-2; 1983 C06804 HMDB01859 2238 152.1 p-acetamidophenylglucuronide 120595-80-4; 4022661 HMDB10316 1377 326.1 2-hydroxyacetaminophen sulfate* 1703 246.1 2-methoxyacetaminophen sulfate* 1977 260.1 3-(cystein-S-yl)acetaminophen* 5233914 1960 271.2 benzoylecgonine 519-09-5; 442997 C10847 3100.7 290.2 saccharin 81-07-2; 5143 D01085 2013 182.1 stachydrine 4136-37-2; 115244 C10172 HMDB04827 860 144.1 caffeine 58-08-2; 2519 C07481 HMDB01847 2820 195.1 paraxanthine 611-59-6; 4687 C13747 HMDB01860 2444 181.2 theobromine 83-67-0; 5429 C07480 HMDB02825 2136 181.1 1,7-dimethylurate 33868-03-0; 91611 C16356 HMDB11103 1607 195.1 erythritol 149-32-6; C00503 HMDB02994 1517.5 217

Having described the invention in detail, it will be apparent that modifications, variations, and equivalent embodiments are possible without departing from the scope of the invention defined in the appended claims. Furthermore, it should be appreciated that all examples in the present disclosure are provided as non-limiting examples.

EXAMPLES

The following non-limiting examples are provided to further illustrate embodiments of the invention disclosed herein. It should be appreciated by those of skill in the art that the techniques disclosed in the examples that follow represent approaches that have been found to function well in the practice of the invention, and thus can be considered to constitute examples of modes for its practice. However, those of skill in the art should, in light of the present disclosure, appreciate that many changes can be made in the specific embodiments that are disclosed and still obtain a like or similar result without departing from the spirit and scope of the invention.

Example 1 Experiments (“Cohort A”)

Study population and sample collection: The initial study population was derived from two clinic sites in Seattle with enrollment between November 2003 and June 2010: the Public Health, Seattle and KingCounty Sexually Transmitted Diseases Clinic (STD clinic; n=30) and the University of Washington's Women's Research Clinic (WRC; n=30). A case-control study comprising 40 women with BV and 20 women without BV was conducted. BV was defined by both Amsel criteria (21) and Gram stain interpretation using the Nugent method (22); women were classified BV-negative if negative by both diagnostic measures. Cases and controls were randomly selected from both clinics in a 2:1 ratio, with the goal of having a better representation of women with BV given the increased bacterial heterogeneity associated with this condition. All women provided written informed consent, and the studies were approved by Review Boards at the Fred Hutchinson Cancer Research Center and the University of Washington.

Studies were aimed at using mass spectrometry to link specific metabolites with particular bacteria detected in the human vagina by PCR. BV was associated with strong metabolic signatures across multiple pathways affecting amino acid, carbohydrate and lipid metabolism, highlighting the profound metabolic changes in BV. These signatures were associated with the presence and concentrations of particular vaginal bacteria including some bacteria yet to be cultivated, thereby providing clues as to the microbial origin of many metabolites.

A pelvic examination with speculum was performed for collection of samples. Polyurethane foam swabs (Epicenter Biotechnologies, Madison, Wis.) were brushed against the lateral vaginal wall and stored at −80° C. until DNA extraction for bacterial PCRs. Vaginal fluid was also collected for Gram staining, pH, saline microscopy and potassium hydroxide preparation. Cervicovaginal lavage fluid (CVL) was collected by instilling 10 mL sterile saline into the vagina, aspirating, and storing at −80° C. prior to processing for metabolomics studies.

DNA Extraction and quantitative PCR: DNA was extracted using the Ultra Clean Soil DNA Kit or the Bacteremia Kit (Mobio, Carlsbad, Calif.), which gave similar results. DNA was eluted in 150 μL buffer and diluted 1:1 in 1 mM Tris, 0.1 mM EDTA (TE) buffer. Sham swabs without human contact were processed as controls to assess contamination from reaction buffers or sample collection swabs. Samples were evaluated for presence of PCR inhibitors using a qPCR assay targeting a segment of exogenously added jellyfish DNA; inhibition was defined as a delay in the threshold cycle of >2 cycles compared with no template controls (68). Control assays targeting the human 18S rRNA gene were performed to ensure that swabs contained human tissue (68). DNA from each sample was subjected to a panel of 14 qPCR assays to measure concentrations of bacteria. The bacteria targeted included three members of the Clostridia/es order which are highly specific for BV, designated BV-associated bacterium-1 (BVAB-1), BVAB-2, and BVAB-3 (8). Other vaginal bacteria targeted included Gardnerella vaginalis, Leptotrichia/Sneathia spp., Megasphaera-like bacterium (Type 1 & Type 2), Atopobium vaginae, Lactobacillus crispatus, Lactobacillus jensenii, and Lactobacillus iners (69, 70). Four additional qPCR assays targeting an Eggerthella-like bacterium, Prevotella amnii, Prevotella timonensis and Prevotella buccalis using 16S rRNA gene-specific primers and taxon-directed hydrolysis probes were developed. Assay conditions, primer and probe sequences for qPCR assays developed in this study are presented in Table 2. Core PCR reagents were obtained from Applied Biosystems (Carlsbad, Calif.), and master mixes contained buffer A (1 mM), deoxynucleotide triphosphates (1 mM), magnesium (3 mM), AmpErase uracil-N-glycosylase (0.05 U), and AmpliTaq Gold polymerase (1-1.5 U) per reaction. Primers were added at 0.8 per reaction and final probe concentration was 150 μM. Assays underwent 45 cycles of amplification on the StepOnePlus™ Real-time PCR System (Life Technologies, Grand Island, N.Y.). Plasmid standards were run in duplicate from 106 to 2.5 copies. Specificity and sensitivity testing was conducted as previously described (69). Two microliters of DNA (diluted 1:1 with TE buffer) were added to each qPCR reaction and values are reported as 16S rRNA gene copies per swab.

TABLE 2 Primer and probe sequences Amplicon PCR Assay PCR Conditions Size Primer/Probe Primer/Probe Sequence Eggerthella- 56° C. annealing,  84 bp Egger-like_126F 5′-GACCAACCTGCCTCTTACATT-3′ like 39 s 72° C. extension, Egger-like_210R 5′-G CATACATCATGTG ATATGTG C-3′ 30 s Egger-like_155- 5′-FAMAAAAGAAATTCTGGCTAATACCAA- 178_pb MG BN FQ-3′ Prevotella 57° C. annealing, 171 bp Pbuccalis_455F 5′-G CG CGACGTGTCGTG CA-3′ buccalis 39 s 72° C. extension, Pbuccalis_626R 5′-CCGGTTGAGCCGGTACA-3′ 30 s P.buccaIis_ 5′-FAM-CG CCAG RTAAG CGTGTTGMG 587-604_pb BN FQ-3′ Prevotella 64° C. anneal/  90 bp Ptimonensis 578F 5′-GAG CGTAG G CTGTCTATTAAG C-3′ timonensis extend, 60 Ptimonensis_668R 5′-CTTCCTG CATACTCAAGTCG A C Ptimonensis_ 5′-FAM-ATTTACCGGCTCAACCGGTGGMG 609-629_pb BN FQ-3′ Prevotella 59° C. annealing,  69 bp Pamnii_989F 5′-GGCTTGAATTG CAGATGTTTATAT-3′ amnii 39 s 72° C. extension, Pamnii_1058R 5′-CCATGCAGCACCTTCACAAAT-3′ 30 s Pamnii_ 5′-FAM-AG ATGATATATTCCCTTCG G- 1014-1033_pb MG BN FQ-3′ MG-Minor groove binder, FAM-fluorescein label, BNFQ-Black Hole Non-fluorescent quencher

Broad-range PCR and pyrosequencing of 16S rRNA gene amp/icons: Broad-range 16S rRNA gene PCR with pyrosequencing was performed using 454 Life Sciences FLX technology (Roche, Branford, Conn.) targeting the V3-V4 region of the 16S-rRNA gene for a subset of samples from 20 women with BV and 10 women without BV, a subset of the cohort described previously (11). Sequence reads were classified using a phylogenetic placement tool pplacer (71) and a curated reference set of vaginal bacteria (11). All sequence reads were deposited in the NCBI Short Red Archive (5RA051298) (11). Measurement of levels of biochemicals: Chromatographic separation and full-scan mass spectroscopy (MS) were performed using the Metabolon (Durham, N.C.) platform (72-74). Briefly, CVL samples were extracted to remove the protein fraction while allowing maximal recovery of small molecules using the MicroLab STAR® system (Hamilton, Reno, Nev.). The resulting extract was split into equal parts for analysis by gas chromatography/mass spectrometry (GC/MS) and liquid chromatography/mass spectrometry (LC/MS). Samples were dried by placing them on a Zymark TurboVap® (American Laboratory Trading, East Lyme Conn.) and stored at −80° C. Aliquots of water and solvents used in the extraction were included as controls to assess the contribution of the separation process and extraction methods to the compound signals. Additional samples with known compositions were also included with every run to ensure that there were no process deviations in each run. A reference library of 1000 purified standards with known chemical structures was used to identify the small molecules from the samples by matching chromatographic properties and mass spectral signatures.

Data analysis: Metabolite data were median-centered, and missing values imputed as the minimum observed for that metabolite; median values were then log-transformed. Pyrosequencing taxonomic counts and qPCR measures were log-transformed. Welch's two sample t-tests were used to compare metabolites between BV-positive and BV-negative groups. An estimate of false discovery rate (q-value) was calculated to account for multiple comparisons. A low q-value (<0.1) indicates high confidence in a result. Eighty-three metabolites (30%) with largest variability (inter-quartile range) were used to hierarchically cluster samples using Euclidean distance (FIG. 1); identification of four sample groups maximizes silhouette width. To explore the relationship between relative abundances of metabolite and pyrosequencing reads (FIG. 2) or qPCR measures (FIG. 3), Pearson correlations were calculated between metabolite and pyrosequencing reads or qPCR levels; these were used in hierarchical clustering using Euclidean distance. Data transformation was performed in R (http://crans-project.org) (75). Lasso regression with binomial response was used to identify metabolites strongly associated with Amsel clinical criteria (Table 3). The number of metabolites retained was set to the largest value within 1 standard deviation of the cross-validation error. Analysis was performed with the R package glmnet (76).

TABLE 3 Association of metabolites with individual clinical criteria Bacterial Taxa Regression co-efficient′ BV Status deoxycarnitine 0.5 phenylalanine −0.299 N-acetylputrescine 0.254 pipecolate 0.148 cadaverine 0.025 Elevated pH cadaverine 0.0657 N-acetylputrescine 0.0577 lactate −0.0505 glutamate −0.0249 sphingosine −0.0137 tyrosine −0.0083 tyramine 0.0033 Presence of Clue Cells deoxycarnitine 0.2519 glycylproline −0.203 glutathione, reduced (GSH) −0.0311 pipecolate 0.0024 Presence of Amine Odor N-acetylputrescine 0.302 lactate −0.072 phenylalanine −0.049 Vaginal Discharge agmatine 0.14 cadaverine 0.11

Metabolite Summary of Cohort A

Characteristics of the 60 women from cohort A are presented in Table 4. There was low prevalence of other infections including Candida (8%), Trichomonas vaginalis (3%), Chlamydia trachomatis (3%), and Neisseria gonorrhoeae (0%). Cases included women with BV by both Amsel criteria and Nugent score; controls did not have BV by both criteria. Elevated pH>4.5 was the only Amsel criterion noted in all cases (n=40); vaginal fluid from 20% of control women had pH>4.5 (n=4). Presence of >20% clue cells and a positive whiff test (amine odor) were both observed in 83% of cases (n=33); clue cells and a positive whiff test were not detected in the control group. A thin homogeneous discharge that is present in some women with symptomatic BV was noted in 85% of cases (n=34), and 5% (n=1) of women in the control group.

TABLE 4 Characteristics of study participants according to case or control status Cohort A Cohort B Characteristic Total (n = 60) Cases (n = 40) Controls (n = 20) Total (n = 60) Cases (n = 40) Controls (n = 20) Age, Median (range) 26 (17-56) 26 (19-42) 26 (17-56) 29 (19-49) 29 (19-45) 30 (21-49) Race (self-defined)¹ Black or African American 13 (22) 10 (25) 3 (15) 24 (40) 22 (55) 2 (10) White 41 (68) 27 (68) 14 (70) 28 (47) 14 (35) 14 (70) Other 4 (7) 2 (5) 2 (10) 7 (12) 4 (10) 3 (15) Don't Know/Declined to 2 (3) 1 (3) 1 (5) 1 (1) 0 (0) 1 (5) provide data Menses, at visit 4 (7) 3 (8) 1 (5) 5 (8) 4 (10) 1 (5) Vaginal douching, past week² 4 (7) 3 (8) 1 (5) 3 (5) 2 (5) 1 (5) Antibiotic use, past month³ 5 (8) 5 (13) 0 (0) 5 (8) 3 (7.5) 2 (10) Hormonal contraceptive, past month⁴ 7 (60) 3 (8) 4 (20) 18 (30) 9 (23) 9 (45) Sexual activity Sex, past 3 months⁵ 55 (92) 37 (93) 18 (90) 50 (83) 33 (83) 17 (85) Sex with female partner⁶ 13 (22) 9 (23) 4 (20) 9 (15) 7 (18) 2 (10) Sex with male partner⁷ 50 (83) 33 (83) 17 (85) 49 (82) 34 (85) 15 (75) Amsel criterion - Vaginal Discharge⁸ Normal 18 (30) 5 (13) 13 (65) 18 (30) 0 (0) 18 (90) Abnormal 35 (58) 34 (85) 1 (5) 35 (58) 34 (85) 1 (5) Other 7 (11) 1 (3) 6 (30) 7 (12) 6 (15) 1 (5) Amsel criterion - pH 4.5 and less 16 (27) 0 (0) 16 (80) 16 (27) 1 (2) 15 (75) Greater than 4.5 44 (73) 40 (100) 4 (20) 44 (73) 39 (98) 5 (25) Amsel criterion - Clue Cells Absent 21 (35) 2 (5) 19 (95) 18 (30) 0 (0) 18 (90) Less than 20% (few) 5 (8) 4 (10) 1 (5) 4 (7) 2 (5) 2 (10) Greater than 20% (many) 33 (55) 33 (83) 0 (0) 38 (63) 38 (95) 0 (0) Amsel criterion - Whiff Test Negative 27 (45) 7 (18) 20 (100) 28 (47) 8 (20) 20 (100) Positive 33 (55) 33 (83) 0 (0) 32 (53) 32 (80) 0 (0) Other infections Trichomonas vaginalis 2 (3) 2 (5) 0 (0) 1 (2) 1 (2) 0 (0) Chlamydia trachomatis ⁹ 2 (3) 1 (3) 1 (5) 0 (0) 0 (0) 0 (0) Neisseria gonorrhoeae ⁹ 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Candida 5 (8) 1 (3) 4 (20) 4 (7) 3 (8) 1 (5) Data represent number (%) of participants. Cases included women with BV by both Amsel criteria (21) and by interpretation of Gram stain using Nugent score (22). Controls included women who did not have BV by both criteria. ¹Study participants were able to select more than one category for race. Black/African American and white indicate women who selected only these categories. ²Douching data not available for 1 study participant who did not provide data. ³Antibiotic use data not available for 4 study participants. ⁴Hormonal contraceptive data not available for 4 study participants who did not provide data. ⁵Sex data not available for 2 study participants who did not provide data. ⁶Female sex partner data not available for 9 study participants who did not provide data. ⁷Male sex partner data not available for 2 study participants who did not provide data. ⁸Abnormal vaginal discharge indicates those with a thin homogenous discharge that is consistent with BV. Women with vaginal discharge that was not normal, or did not have a thin homogeneous discharge were placed in the other category. ⁹ Chlamydia trachomatis and Neisseria gonorrhoeae data not available for 5 study participants.

279 known metabolites was detected in vaginal fluid from women with and without BV. There were significant differences in levels of 173 metabolites (62% of the 279 detected) on comparison of women with and without BV (q-value=0.02). Women with BV had higher levels of 55 biochemicals (20%), and lower levels of 118 biochemicals (42%). A summary of metabolites altered in BV based on pathway is provided in Table 5.

TABLE 5 Summary of biochemicals altered based on super pathways Biochemicals Biochemicals higher in BV lower in BV Super Pathway¹ Total Altered Number (%) Number (%) Amino Acid 90 32 (35.6) 35 (38.9) Peptide 28 0 (0.0) 24 (85.7) Carbohydrate 27 3 (11.1) 15 (55.6) Energy 6 2 (33.3) 0 (0.0) Lipid 74 12 (16.2) 27 (26.5) Nucleotide 17 3 (17.6) 8 (47.1) Cofactors & Vitamins 13 3 (23.1) 6 (46.2) Xenobiotics 24 0 (0.0) 3 (12.5) ¹Biochemicals categorized according to KEGG pathways.

Hierarchical clustering depicting this set of the most variable metabolites measured in CVL samples from all women resulted in the creation of four groups, of which 2 clusters were populated by women with BV. Cluster-I had 12 women without BV, and Cluster-II comprised 15 women with BV. Cluster-III included women without BV. Cluster-IV included 25 women with BV and 1 woman without BV (Subject 58) (FIG. 1). Vaginal fluid from Subject 58, the outlier in Cluster-IV, had an elevated pH of 5.6 and a Nugent score of 6, defined as intermediate on this scale.

Example 3 Alterations in Metabolism (“Cohort A”)

Amino acids: 19 of 20 important amino acids (95%) that are incorporated into proteins were detected using the Metabolon platform (Table 1). Levels of 18 of 19 amino acids detected (94.7%) were lower among cases; this was statistically significant for 16 of 18 amino acids (84.9%). There were higher concentrations of amino acid catabolites in women with BV (Table 1). Examples of such catabolites include: cadaverine (p<0.001) and pipecolate (p<0.001) in the lysine degradation pathway; tyramine (p<0.001), 4-hydroxyphenylacetate (p<0.001) and 3-(4-hydroxyphenyl)propionate (p<0.001) in the tyrosine pathway; tryptamine (p<0.001) in the tryptophan pathway; and citrulline (p<0.001) in the arginine pathway. There was marked elevation of the polyamine putrescine (p<0.001), along with lower levels of putrescine precursors arginine (p<0.001) and ornithine (p<0.001) in women with BV. The polyamine spermine (p<0.001), a typical product of putrescine degradation, was lower in BV. Enhanced protein/amino acid catabolism in BV was further supported by detection of lower levels of dipeptides (n=28); this was statistically significant for 24 dipeptides (85.7%). Levels of oxidized (p<0.001) and reduced (p=0.049) glutathione were lower in BV.

Carbohydrates: Of the four aminosugars detected, N-acetylneuraminate, commonly known as sialic acid, was higher in BV (p<0.001), while glucosamine levels were lower (p=0.0059). Glucose oligosaccharides of varying length including maltotriose (p=0.0095), maltotetraose (p=0.0016), maltopentaose (p<0.001), and maltohexaose (p<0.001) were all lower in BV. Likewise, lower levels of simple sugars and sugar alcohols such as lactate (p<0.001), fructose (p=0.0012), and mannitol (p=0.001) were noted; galactose (p<0.001) and threitol (p<0.001) were significantly higher in BV. Succinate levels were also higher in BV (p<0.001).

Nicotinamide adenine dinucleotide (NAD): NAD, an essential co-factor for energy metabolism, was below the limit of detection in 82.5% of BV cases and in only 10% of controls (p<0.001). Nicotinamide levels, a precursor to NAD biosynthesis, were also lower in BV (p=0.06), while nicotinate (p=0.002) levels were higher.

Lipids: Multiple components of lipid metabolism were affected in BV. The arachidonic acid catabolite 12-hydroxyeicosatetraenoic acid (12-HETE) was higher in BV (p<0.001) while arachidonate was lower (p=0.0075). Deoxycarnitine, a precursor to carnitine was higher in BV (p<0.001), while carnitine was lower (p<0.001). Ascorbic acid, which is essential to the synthesis of carnitine, was lower in BV (p<0.001). Acyl-carnitines such as acetylcarnitine (p<0.001), propionylcarnitine (p<0.001), and butyryl carnitine (p<0.001) were also lower in BV. Of the four monohydroxy fatty acids detected, levels of 4-hydroxybutyrate (p<0.001) and 13-hydroxyoctadecadienoic acid (13-HODE) (p=0.0042) were higher in BV. Biochemicals involved in glycerol metabolism including glycerol (p=0.046) and glycerol-3-phosphate (p<0.001) were lower in BV.

Example 4 Association Between Metabolites and Bacterial Abundance and Concentrations in Cohort A

Association between metabolites and bacterial abundance: Pearson correlation coefficients were used to investigate associations between bacterial abundance and metabolite abundance in vaginal samples. Specifically, the abundance of 30% of the most variable metabolites and relative abundance of bacteria detected by broad-range PCR with pyrosequencing was analyzed in a subset of 20 women with BV and 10 women without BV. A group of ten BV-associated bacteria were highly correlated with metabolites typically associated with BV including succinate, cadaverine, putrescine, tyramine and deoxycarnitine (FIG. 2). Megasphaera sp. type 1 had the highest correlation coefficient with the fatty acid, 12-HETE (0.48). A second cluster of BV-associated bacteria including BVAB1, BVAB3, Megasphaera sp. type 2 and several Prevotella species such P. amnii, P. disiens, P. buccalis and P. bivia showed similar positive associations with the above-mentioned metabolites, but the correlations were less pronounced. The three lactobacilli, L. crispatus, L. jensenii and L. iners clustered together and exhibited metabolite correlation patterns that overall were in contrast to the patterns found with BV-associated bacteria.

Association between metabolites and bacterial concentrations: Bacteria were selected for qPCR based on relative abundance measured by broad-range PCR and pyrosequencing in a subset of samples (FIG. 2), and on associations made in previous studies that have demonstrated sensitivity, specificity (31) and significance of these bacteria in BV (11, 20, 32). Associations of concentrations of key vaginal bacteria with the 30% most variable metabolites were investigated using Pearson correlation coefficients (FIG. 3). L. crispatus, L. jensenii and L. iners clustered together, while the BV-associated bacteria clustered as two groups. Group-1 comprised Leptotrichia/Sneathia spp., BVAB2, Megasphaera spp., Prevotella timonensis, Atopobium vaginae, Gardnerella vaginalis, Eggerthella-like bacterium and Prevotella buccalis. Group-2 comprised BVAB1, BVAB3 and Prevotella amnii. Clustering patterns noted here also reflected patterns observed in the association analysis of metabolites with bacteria detected by broad range PCR and pyrosequencing. L. crispatus and L. jensenii, lactobacilli typically associated with vaginal health, exhibited metabolite correlation patterns that were similar; these were in striking contrast to those exhibited by BV-associated bacteria (FIG. 3). L. iners exhibited correlation patterns that were intermediate between those of BV-associated bacteria and those of L. crispatus/L. jensenii. Concentrations of L. crispatus and L. jensenii had strong positive correlations with several amino acids and dipeptides, but were negatively correlated with amino acid catabolites (tyramine, pipecolate, cadaverine) and polyamines (putrescine, agmatine). L. iners was negatively correlated with some amino acids and dipeptides (glutamate, glycylleucine), but positively correlated with others (proline, threonine, aspartate, serine, and valinylglutamate). L. crispatus and L. jensenii were positively correlated with sugars such as maltose, maltotriose, and maltohexose, lipid metabolism biochemicals such as arachidonate and carnitine, as well as lactate, urea, and reduced glutathione. These two lactobacilli were negatively correlated with N-acetylneuraminate, succinate, the carnitine precursor deoxycarnitine, the eicosanoid 12-HETE, the fatty acid 13-HODE, and the nucleobase uracil. BV-associated bacteria typically exhibited correlation patterns with metabolites that were opposite to that exhibited by L. crispatus and L. jensenii. Among BV-associated bacteria, BVAB1 displayed specific differences in metabolite correlation patterns when compared with BV-associated bacteria from Group-1. BVAB1 was negatively correlated with N-acetylaspartate, 12-HETE, fatty acids such as eicosenoate and dihomo linoleate; these metabolites had positive associations with Group-1 BV-associated bacteria. BVAB3 and P. amnii, members of Group-2 BV-associated bacteria, exhibited metabolite correlation patterns that were similar to each other.

Example 5 Alterations in Key Vaginal Bacteria and Metabolite Concentration with Changes in BV Status in Cohort 1

Limited longitudinal data are presented for 8 women who returned for follow-up visits 4 weeks after baseline sample collection per study protocol (FIG. 5, FIG. 7). Participants diagnosed with BV were treated with metronidazole. Study participants 19, 21, 23 and 25 were cured of BV at the follow-up visit (FIG. 5). All four participants had high concentrations of lactobacilli at their follow-up visits and increased concentrations of metabolites negatively associated with BV. Women with high concentrations of L. crispatus at follow-up had high concentrations of metabolites negatively associated with BV. Women with high concentrations of L. iners also showed increased concentrations of metabolites negatively associated with BV, but these shifts were not as dramatic as increases seen in women with L. crispatus dominant communities (FIG. 5). Study participants 4 and 7 did not have BV at either time point and had high concentrations of lactobacilli at both time points (FIG. 7). High concentrations of metabolites negatively associated with BV were also noted at baseline and follow-up. Study participants 12 and 28 had recurrent BV after antibiotic treatment. In both participants, concentrations of metabolites associated with BV declined at the follow-up visit, but there was no associated increase in metabolites negatively associated with BV (FIG. 7). In this longitudinal analysis, changes in the microbiota were associated with shifts in metabolites in the same subject, whereas stability of the microbiota was associated with fewer changes even after patients received antibiotic therapy.

Example 6 Validation Study (Cohort B)

Study population and sample collection: Cohort B in the independent validation study also comprised 40 women with BV and 20 women without BV enrolled in the STD clinic between April 2011 and August 2013. BV definitions and sample collection procedures were the same as Cohort A. An additional 10 women with intermediate (4-6) Nugent scores were included to determine if their metabolite profiles differed from those who had BV (Nugent 7-10) or those who had scores of Nugent 0-3. Of these 10 women, 6 were BV negative and 4 were BV positive by Amsel clinical criteria. All women provided written informed consent, and the study was approved by Institutional Review Board at the Fred Hutchinson Cancer Research Center.

DNA Extraction and molecular methods: DNA was extracted using the Bacteremia Kit (Mobio, Carlsbad, Calif.) and eluted in 150 μL buffer and diluted 1:1 in 1 mM Tris, 0.1 mM EDTA (TE) buffer. The V3-V4 region of the 16S-rRNA gene was targeted for broad-range 16S-rRNA gene PCR with pyrosequencing using 454 Life Sciences Titanium technology (Roche, Branford, Conn.). Reads were processed using the same methods as Cohort A, and reads were deposited in the NCBI Short Red Archive (SRP056030).

Measurement of levels of biochemicals: Sample preparation: Commercially available pooled serum (Innovative Research, Novi, Mich.) was used as quality control (QC) sample and aqueous metabolites were extracted using methanol (250 The supernatant (200 μL) obtained post-centrifugation (20,800×g for 10 min) was dried for 90 min using a Vacufuge Plus evaporator (Eppendorf, Hauppauge, N.Y.) and reconstituted in 600 μL 40% Solvent A (40 mM ammonium acetate in H₂O+0.3% acetic acid) and 60% Solvent B (acetonitrile+0.3% acetic acid) containing 5.13 μM L-tyrosine-¹³C₂ and 22.54 μM sodium-L-lactate-¹³C₃ (Cambridge Isotope Laboratory). The isotope-labeled internal standards helped monitor LC-MS assay performance. Samples were filtered through 0.45 pm PVDF filters (Phenomenex, Torrance, Calif.) prior to LC-MS analysis. Acetonitrile, ammonium acetate, methanol, and acetic acid (LC-MS grade) were obtained from Fisher Scientific (Pittsburgh, Pa.) and stable isotope-labeled tyrosine and lactate internal standards (>99% pure) from Cambridge Isotope Laboratories, Inc. (Tewksbury, Mass.). The QC sample was injected every 10 vaginal samples. Vaginal swab samples and CVL (100 μL) were processed using the same procedure as the QC sample, but extracted using 850 μL of methanol. Sham samples (saline solution and swabs without human contact) were included to assess background signals (chemical impurities present in materials used to collect vaginal fluid). Blank saline solution and swab samples were injected once each for every 10 vaginal fluid samples.

Chromatography Conditions: The LC system was composed of two Agilent 1260 binary pumps, an Agilent 1260 auto-sampler and Agilent 1290 column compartment containing a column-switching valve (Agilent Technologies, Santa Clara, Calif.). Each sample was injected twice, 10 μL for analysis using negative ionization mode and 2 μL for analysis using positive ionization mode. Both chromatographic separations were performed in HILIC mode on two parallel SeQuant ZIC-cHILIC columns (150×2.1 mm, 3.0 pm particle size, Merck KGaA, Darmstadt, Germany). While one column was performing the separation, the other column was reconditioning in preparation for the next injection. The flow rate was 0.300 mL/min, auto-sampler temperature was kept at 4° C., the column compartment was set at 40° C., and total separation time for each ionization mode was 18 min. The mobile phase was composed of Solvents A and B; the gradient conditions for both separations were identical and are as follows: 0-2 min, 25% Solvent A, 75% Solvent B; 2-5 min, 25 to 70% Solvent A, linear gradient; 5-9 min, 70% Solvent A; 9-11 min 70 to 25% Solvent A, linear gradient; 11-18 min, 25% Solvent A.

Mass Spectrometry (MS) and data processing: After the chromatographic separation, MS ionization and data acquisition were performed using an AB Sciex QTrap 5500 mass spectrometer (AB Sciex, Toronto, ON, Canada) equipped with electrospray ionization (ESI) source. The instrument was controlled by Analyst 1.5 software (AB Sciex, Toronto, ON, Canada). Targeted data acquisition was performed in multiple-reaction-monitoring (MRM) mode. Additional assays for 19 metabolites of interest based on results from Cohort A were developed wherein biochemicals using the Metabolon platform (Table 6) were measured. 104 and 76 MRM transitions in negative and positive mode, respectively, were monitored (180 transitions total) (Table 6). The source and collision gas was N2 (99.999% purity). The ion source conditions in negative mode were: Curtain Gas (CUR)=25 psi, Collision Gas (CAD)=high, Ion Spray Voltage (IS)=−3.8 KV, Temperature (TEM)=500° C., Ion Source Gas 1 (GS1)=50 psi and Ion Source Gas 2 (GS2)=40 psi. The ion source conditions in positive mode were: Curtain Gas (CUR)=25 psi, Collision Gas (CAD)=high, Ion Spray Voltage (IS)=3.8 KV, Temperature (TEM)=500° C., Ion Source Gas 1 (GS1)=50 psi and Ion Source Gas 2 (GS2)=40 psi. The extracted MRM peaks were integrated using MultiQuant 2.1 software (AB Sciex, Toronto, ON, Canada). Standard compounds corresponding to measured metabolites were purchased from Sigma-Aldrich (Saint Louis, Mo., USA) and Fisher Scientific (95-99% pure).

Data analysis: Metabolite data and pyrosequencing reads were processed and analyzed as described for Cohort A.

TABLE 6 Cohort B - University of Washington NW-MRC Platform Measured Pos/Neg Pos/Neg using Mean Values Welch's Two Sample t-Test Super Metabolon Biochemical Name Platform Comp ID KEGG HMDB Neg Pos p-value q-value Fold Change Pathway Platform 12-HETE LC/MS neg 5312983 C14777 HMDB06111 0.549761 2.153909 0.0058 0.0225 3.918** Lipid Yes 13-HODE LC/MS neg 5282948 C14767 HMDB61708 0.296921 4.872555 0.0004 0.0023 16.410** Lipid Yes 1-Methyladenosine LC/MS pos 27476 C02494 HMDB03331 13.89231 1.019602 0.2533 0.3109 0.073 Nucleotide No 2-Aminoadipate LC/MS neg 469 C00956 HMDB00510 1.083608 1.236584 0.5614 0.6032 1.141 Amino Acid Yes 2-Hydroxyglutarate LC/MS neg 43 C02630 HMDB59655 3.932806 1.095001 0.0389 0.0655 0.278 Lipid Yes 4-Hydroxybutyrate LC/MS pos 10413 C00989 HMDB00710 0.949666 1.009497 0.1147 0.1655 1.063 Lipid Yes 5-Arninoyaleric Acid LC/MS pos 138 C00431 HMDB03355 0.099272 3.554135 <0.001 <0.001 35.802** Amino Acid Yes Adenine LC/MS neg 190 C00147 1.42114 0.997052 0.3296 0.3871 0.702 Nucleotide Yes Adenosine LC/MS pos 60961 C00212 HMDB00050 2.789559 0.829478 0.0190 0.0392 0.297* Nucleotide Yes Adenylosuccinate LC/MS neg 195 C03794 HMDB00536 2.850905 1.945559 0.4879 0.5415 0.682 Nucleotide No Adipic Acid LC/MS neg 196 C06104 HMDB00448 0.969576 1.041395 0.3615 0.4197 1.074 Caprolactam Degradation No Alanine LC/MS pos 5950 C00041 HMDB00161 1.837288 0.955452 0.1784 0.2435 0.520 Amino Acid Yes Allantoin LC/MS neg 204 C01551 HMDB00462 1.512457 0.908111 0.1484 0.2082 0.600 Nucleotide No Alpha-Ketoglutaric Acid LC/MS neg 51 C00026 HMDB00208 0.973055 1.024005 0.5515 0.5989 1.052 Energy No AMP LC/MS neg 15938965 C00020 HMDB00045 2.399105 0.886976 0.0053 0.0225 0.370* Nucleotide Yes Anthranilate LC/MS neg 227 C00108 HMDB01123 2.854806 0.943821 0.0137 0.0337 0.331* Amino Acid No Arachidonate LC/MS neg 444899 C00219 HMDB60102 1.034647 0.975074 0.0160 0.0377 0.942* Lipid Yes Arginine LC/MS pos 232 C00062 HMDB00517 5.047576 0.863601 0.0065 0.0233 0.171* Amino Acid Yes Ascorbic Acid (Vit. C) LC/MS neg 54670067 C00072 HMDB00044 11933.54 9069.362 0.7750 0.7987 0.760 Cofactors and Vitamins Yes Asparagine LC/MS pos 6267 C00152 HMDB00168 19.02775 1.777006 0.0257 0.0509 0.093* Amino Acid No Aspadic Acid LC/MS pos 5960 C00049 HMDB00191 4.385856 0.750243 0.0165 0.0379 0.171* Amino Acid Yes Biotin LC/MS neg 171548 C00120 HMDB00030 4.346047 0.965599 0.0681 0.1090 0.222 Cofadors and Vitamins No Cadaverine LC/MS pos 273 C01672 HMDB02322 0.050142 3.857881 <0.001 <0.001 76.940** Amino Acid Yes Carnitine LC/MS pos 2724480 C00487 HMDB00062 3.279169 0.764733 0.0274 0.0521 0.233* Lipid Yes Choline LC/MS pos 305 C00114 HMDB00097 2.077764 1.520472 0.5026 0.5517 0.732 Cofactors and Vitamins No Citraconic Acid LC/MS neg 643798 C02226 HMDB00634 1.018945 1.092198 0.3098 0.3681 1.072 Amino Acid No Citrulline LC/MS neg 833 C00327 HMDB00904 1.667773 0.977009 0.2058 0.2598 0.586 Amino Acid Yes Creatine LC/MS pos 586 C00300 HMDB00064 2.444336 0.842549 0.0104 0.0309 0.345* Amino Acid Yes Creatinine LC/MS pos 588 C00791 HMDB00562 2.874441 0.953764 0.0347 0.0603 0.332 Amino Acid Yes Cystamine LC/MS pos 2915 N/A N/A 2.252528 0.949694 0.0690 0.1090 0.422 Amino Acid No Cysteine LC/MS pos 5862 C00097 HMDB00574 12.56652 1.389119 0.0279 0.0522 0.111* Amino Acid Yes Cystine LC/MS pos 67678 C00491 HMDB00192 11.15403 0.579027 0.0145 0.0349 0.052* Amino Acid No Cytosine LC/MS pos 597 C00380 HMDB00630 1.312866 1.543991 0.7135 0.7586 1.176 Nucleotide No Dimethylglycine LC/MS pos 673 C01026 HMDB00092 0.918006 2.008823 0.0294 0.0529 2.188** Cofactors and Vitamins No D-Leucic Acid LC/MS neg 439960 C03264 HMDB00624 0.746823 4.282549 0.0131 0.0336 5.734** Amino Acid No Epinephrine LC/MS pos 5816 C00788 HMDB00068 1.038287 0.952361 0.0498 0.0824 0.917 Amino Acid No Erythrose LC/MS neg 439574 C01796 HMDB02649 1.208405 1.314378 0.4795 0.5381 1.088 Carbohydrate No F168P/F26BP/G16BP LC/MS neg 172313/ C00354/ HMDB01058/ 2.395754 0.864547 0.0009 0.0046 0.361 Carbohydrate Yes 105021/ C00665/ HMDB01047/ 82400 C01231 HMDB03514 Fumaric Acid/Maleic LC/MS neg 444972/ C00122/ HMDB00134/ 1.030087 1.09067 0.4138 0.4696 1.059 Energy Yes Acid 444266 C01384 HMDB00176 G1P/G6P/F6P/F1P LC/MS neg 439165/ C00103/ HMDB01586/ 1.014726 1.302086 0.2004 0.2595 1.283 Carbohydrate Yes 5958/ C000921 HMDB01401/ 69507/ C00085/ HMDB00124/ 10400369 C01094 HMDB01076 Glucoronate LC/MS neg 444791 C00191 HMDB00127 3.565885 0.862001 0.0039 0.0177 0.242* Carbohydrate No Glucose LC/MS neg 79025 C00031 HMDB00122 3.2199 0.582469 <0.001 <0.001 0.181* Carbohydrate Yes Glutamic acid LC/MS pos 611 C00025 HMDB03339 3.943463 0.950986 0.0081 0.0264 0.241* Amino Acid Yes Glutamine LC/MS pos 5961 C00303 HMDB00641 2.096949 0.920155 0.0851 0.1283 0.439 Amino Acid Yes Glutaric Acid LC/MS neg 743 C00489 HMDB00661 0.483471 1.974837 <0.001 0.0001 4.085** Amino Acid No Glyceraldehyde LC/MS neg 751 C02426 HMDB01051 0.597584 1.553495 <0.001 0.0001 2.600** Carbohydrate No Glycerate LC/MS neg 752 C00258 HMDB00139 1.841234 1.003125 0.0750 0.1148 0.545 Carbohydrate Yes Glycerol-3-P LC/MS neg 754 C00093 HMDB00126 0.420476 1.980146 <0.001 <0.001 4.709** Lipid Yes Glycine LC/MS pos 750 C00037 HMDB00123 3.851766 0.854576 0.0289 0.0529 0.222* Amino Acid Yes Guanidinoacetate LC/MS neg 763 C00581 HMDB00128 2.062227 1.084617 0.1909 0.2537 0.526 Amino Acid No Guanosine LC/MS pos 6802 C00387 HMDB00133 5.489016 0.849731 0.0389 0.0655 0.155 Nucleotide Yes Histamine LC/MS pos 774 C00388 HMDB00870 0.360377 5.06166 <0.001 <0.001 14.045** Amino Acid Yes Histidine LC/MS pos 6274 C00768 HMDB00177 3.183509 0.991506 0.0127 0.0336 0.311* Amino Acid Yes Homovanilate LC/MS neg 1738 C05582 HMDB00118 1.061823 1.063368 0.9792 0.9663 1.001 Amino Acid No Hypoxanthine LC/MS neg 790 C00262 HMDB00157 2.5559 0.792758 0.0133 0.0336 0.310* Nucleotide Yes iso-Leucine LC/MS pos 791 C00407 HMDB00172 2.822668 0.886257 0.0112 0.0319 0.314* Amino Acid Yes Kynurenate LC/MS neg 3845 C01717 HMDB00715 0.861798 1.163729 0.1817 0.2446 1.350 Amino Acid Yes Lactate LC/MS neg 612 C001861 HMDB00190 1.529119 0.521579 <0.001 <0.001 0.341* Carbohydrate Yes Leucine LC/MS pos 6106 C00123 HMDB00687 3.152967 0.687161 0.0009 0.0046 0.218* Amino Acid Yes Linolenic Acid LC/MS neg 5280450 C01595 HMDB00673 1.514934 1.302946 0.7589 0.7901 0.860 Lipid Yes Lysine LC/MS pos 5962 C00047 HMDB00182 7.517767 0.753601 0.0071 0.0245 0.100* Amino Acid Yes Malonic Acid/3HBA LC/MS neg 867/441 C00383/ HMDB00691/ 0.894359 1.181646 0.0116 0.0319 1.321** Energy No C01089 HMDB00357 Methionine LC/MS pos 6137 C01733 HMDB00696 10.96199 1.212818 0.0188 0.0392 0.111* Amino Acid Yes MethylSuccinate LC/MS neg 10349 C08645 HMDB01844 14.1235 1.039721 0.0060 0.0226 0.074* Amino Acid No N-Acetylneuraminate LC/MS neg 445063 C00270 HMDB00230 0.359184 1.490695 <0.001 0.0001 4.150** Carbohydrate Yes N-Acetylputrescine LC/MS pos 122356 C02714 HMDB02064 0.332351 5.445013 0.0008 0.0046 16.383** Amino Acid Yes Niacinamide LC/MS pos 936 C00153 HMDB01406 1.771045 1.271236 0.4096 0.4696 0.718 Cofactors and Vitamins No Nicotinate (Niacin) LC/MS neg 938 C00253 HMDB01488 0.916006 1.026653 0.0656 0.1069 1.121 Cofactors and Vitamins Yes Omithine LC/MS pos 6262 C01602 HMDB03374 14.05848 0.768175 0.0087 0.0275 0.055* Amino Acid Yes Oxalic Acid LC/MS neg 971 C00209 HMDB02329 3.292335 0.619838 0.0003 0.0018 0.188* Carbohydrate No Oxaloacetate LC/MS neg 970 C00036 HMDB00223 0.87623 1.162188 0.1093 0.1600 1.326 Energy No Oxidized glutathione LC/MS neg 975 C00127 HMDB03337 2.985064 1.499132 0.1624 0.2247 0.502 Amino Acid Yes Oxypurinol LC/MS neg 4644 C07599 HMDB00786 0.255491 1.923879 0.0000 0.0000 7.530** Nucleotide No Pantothenate LC/MS neg 6613 C00864 HMDB00210 2.612067 1.311789 0.2381 0.2969 0.502 Amino Acid Yes PEP LCMS nag 1005 C00074 HMDB00263 0.94683 2.131465 0.0250 0.0505 2.251** Carbohydrate No Phenylalanine LC/MS pos 6140 C02057 HMDB00159 4.386514 0.568173 0.0001 0.0004 0.130* Amino Acid Yes Pipecolate LC/MS pos 6931663 C00408 HMDB00070 7.316458 0.69474 0.0180 0.0392 0.095* Amino Acid Yes Proline LC/MS pos 145742 C00148 HMDB00162 2.313779 1.453898 0.2626 0.3157 0.628 Amino Acid Yes Propionate LC/MS neg 1032 C00163 HMDB00237 0.898881 1.848487 0.0999 0.1485 2.056 Carbohydrate No Putrescine LC/MS pos 1045 C00134 HMDB01414 0.087085 2.737776 <0.001 <0.001 31.438** Amino Acid Yes Pyruvate LC/MS nag 1060 C00022 HMDB00243 1.601785 1.049359 0.1999 0.2595 0.655 Carbohydrate Yes Reduced glutathione LC/MS neg 124886 C00051 HMDB00125 5.968484 1.030784 0.0267 0.0519 0.173* Amino Acid Yes Ribose-5-P LC/MS neg 439167 C00117 HMDB01548 1.034082 1.011506 0.7387 0.7772 0.978 Carbohydrate No Serine LC/MS pos 5951 C00065 HMDB00187 5.933157 0.782622 0.0185 0.0392 0.132* Amino Acid Yes Shikimic Acid LC/MS nag 8742 C00493 HMDB03070 3.145483 1.477166 0.1259 0.1791 0.470 Amino Acid No Sorbitol LC/MS pos 107428 C00794 HMDB00247 9.470836 0.684095 0.0073 0.0245 0.072* Carbohydrate Yes Spemiidine LC/MS pos 1102 C00315 HMDB01257 1.065615 1.11261 0.8640 0.8815 1.044 Amino Acid Yes Succinate/ LC/MS neg 1110/487 C00042/ HMDB00254/ 0.493851 0.968 <0.001 0.0001 1.960** Energy Yes Methylmalonate C02170 HMDB00202 Taurine LC/MS pos 1123 C00245 HMDB00251 1.653867 0.9972 0.2032 0.2598 0.603 Amino Acid Yes Threonine LC/MS pos 6288 C00188 HMDB00167 5.380847 0.780656 0.0178 0.0392 0.145* Amino Acid Yes Trimethylamine-N- LC/MS pos 1146 C00565 HMDB00906 3.160464 1.040264 0.0117 0.0319 0.329* Redox No oxide (TMAO) Tryptamine LC/MS pos 1150 C00398 HMDB00303 1.583814 53.24717 0.0028 0.0133 33.6207** Amino Acid Yes Tryptophan LC/MS pos 6305 C00078 HMDB00929 7.565738 0.73977 0.0104 0.0309 0.098* Amino Acid Yes Tyramine LC/MS pos 5610 C00483 HMDB00306 0.148074 3.726405 <0.001 0.0001 25.166** Amino Acid Yes Tyrosine LC/MS pos 6057 C00082 HMDB00158 9.126862 0.632987 0.0056 0.0225 0.069* Amino Acid Yes Uracil LC/MS nag 1174 C00106 HMDB00300 1.044215 2.825119 0.0299 0.0529 2.705** Nucleotide Yes Urate LC/MS neg 1175 C00366 HMDB00289 2.842325 0.801884 0.0057 0.0225 0.282* Nucleotide Yes Uridine LC/MS pos 6029 C00299 HMDB00296 3.811939 0.963101 0.0717 0.1114 0.253 Nucleotide Yes Valine LC/MS pos 6287 C00183 HMDB00883 2.192665 1.277254 0.2555 0.3109 0.583 Amino Acid Yes Xanthine LC/MS nag 1188 C00385 HMDB00292 0.987576 0.988861 0.9863 0.9863 1.001 Nucleotide No Xanthurenate LC/MS nag 5699 C02470 HMDB00881 3.145443 0.755646 0.0026 0.0130 0.240* Amino Acid No **indicate metabolites that are higher in BV and statistically significant; *indicates lower in BV and statistically significant; italicized text indicates metabolites that are trending to significance.

Example 6 Validation Study (Cohort B)

An important question is whether metabolites identified by the global metabolic screen in the primary study (Cohort A) are reproducible in other samples using a different platform to measure the metabolites. Hence, in the validation study (Cohort B) a targeted set of metabolites that were identified as significant in the primary study including amino acids, amino acid catabolites, sialic acid, and eicosanoids 12-HETE and 13-HODE (Table 6) were evaluated. The validation cohort included 40 women with BV and 20 women without BV; BV was diagnosed by both Amsel criteria and Nugent score (Table 1). Of the 101 metabolites that were detected by the Northwest Metabolomics Research Center (NW-MRC) platform, 57 metabolites (56.4%) were significantly different between women with and without BV (q<0.05). Of the 57 metabolites, 37 were lower in BV (64.9%) and 20 were higher (35.1%). Most observations made in the primary study were confirmed in the validation study. Examples include lower levels of amino acids in BV, and this was significant for 16/20. Similarly, amino acid catabolites cadaverine (p<0.001), tyramine (p<0.001) and tryptamine (p=0.003) were higher in women with BV. The polyamine putrescine was higher in BV (p<0.001), while precursors arginine (p=0.007) and ornithine (p=0.009) were lower. N-aceytylneuraminate (sialic acid) (p<0.001) and succinate (p<0.001) were higher, and lactate was lower (p<0.001). Components of lipid metabolism, including higher levels of 12-HETE (p=0.006) and 13-HODE (p=0.0004), and lower levels of the 12-HETE precursor, arachidonate (p=0.016) were also corroborated. In some cases such as ascorbate (p=0.775) and oxidized glutathione (p=0.162), similar trends were observed in the primary and validation studies (both lower in BV), but fold change was not statistically significant in the validation study. Likewise, glucose was higher in women without BV (p<0.001), but not statistically significant in the primary study. Pipecolate was lower in BV (p=0.018) in the validation study, but found to be higher in BV in the primary study (p<0.001), and was associated with the presence of clue cells.

As in the primary study, Pearson correlation coefficients were used to link bacteria detected by broad-range PCR and pyrosequencing with the metabolites detected in the validation study (FIG. 8). BV-associated bacteria were highly correlated with metabolites associated with BV such as amino acid catabolites tyramine and histamine, polyamines putrescine and cadaverine, and fatty acids 13-HODE and 12-HETE. In contrast, the lactobacilli were correlated with intact amino acids and glucose among other metabolites. Clustering patterns were similar to that observed in the primary study with the BV associated bacteria clustering as two groups and the lactobacilli clustering together. L. iners exhibited correlation patterns that were intermediate between the BV-associated bacteria and the lactobacilli (FIG. 8).

Example 6 Summary

Research on the human microbiome has been largely focused on describing the composition of microbial communities under conditions of health and disease. Current knowledge of the functional properties of vaginal microbes is just emerging (30, 33). Small molecule metabolites (the metabolome) reflect the enzymatic pathways and complex metabolic networks that drive microbial transformation of host-derived products. The physiological state of the vagina was examined using approaches that integrate microbial community composition with metabolite profiles present in human vaginal fluid. First, metabolites present in vaginal fluid from women with and without BV were determined. Second, vaginal bacterial species was associated with metabolite concentrations using broad-range 16S rRNA gene PCR (to assess representation) as well as taxon directed qPCR (to measure bacterial concentrations). Third, metabolites were correlated with individual clinical criteria used to diagnose BV. And fourth, a set of select metabolites of interest that were identified in the primary study were validated by measuring them in a second set of samples using a different metabolomics platform.

There is a notable delineation of metabolite profiles in women with and without BV across multiple pathways (FIG. 1, Tables 1, 5, 6). The range and magnitude of these differences is striking. Within women with BV, there are at least two sub-types based on the metabolic profiles reflecting different concentrations rather than presence/absence of particular metabolites (FIG. 1). In a recent metabolomics study of eight women with symptomatic BV, clustering analysis resulted in two groups, differentiated by 48 metabolites (30). In the studies described in the Examples, 12/48 metabolites that were reported by Yeoman et al. were detected. Of the 12 metabolites, tryptophan, urea and valine contributed to the differences in the four clusters; the other 9 were not among the top 30% of most variable metabolites presented in FIG. 1. These data support previous studies that have demonstrated that BV is associated with high concentrations of putrescine and cadaverine, and low concentrations of lactate (2, 3, 5, 6, 23-27, 30, 34, 35). However, these data provide additional insight into the global changes in metabolite profiles in BV reflecting numerous pathways, particularly amino acid metabolism.

Lower levels of amino acids and higher levels of amino acid catabolites suggest increased utilization of amino acids in BV. Alternatively, lower amino acid levels in BV could be explained by decreased production of amino acids, but this would not explain the increase in amino acid decarboxylation products. Concomitant with lower levels of amino acids, there were lower levels of dipeptides as well, supporting increased catabolism (Tables 1 & 5). Specific BV-associated bacteria were correlated with presence of amino acid catabolites, whereas L. crispatus and L. jensenii were associated with the presence of intact amino acids and dipeptides. These data support the notion that BV-associated bacteria may use amino acids as a carbon and nitrogen source, in contrast to lactobacilli which are known to metabolize sugars such as glycogen. In line with these findings, another study that performed comparative analysis of Lactobacillus genomes from the human vagina suggested that Lactobacillus genomes were underrepresented in amino acid transport and metabolism, while being overrepresented for carbohydrate transport and metabolism (36). Furthermore, genome analysis of L. iners AB-1 showed that it lacks genes necessary for the de novo synthesis of amino acids with the possible exception of serine, and that approximately 15% of its genome is dedicated to various transport mechanisms, suggesting that it acquires metabolites such as amino acids crucial for survival from the environment (37). This is consistent with our observations that the metabolite profile of L. iners is intermediate to those of L. crispatus/L. jensenii and the BV-associated bacteria.

The amino acid arginine typically serves as a precursor for the generation of polyamines putrescine, spermidine and spermine. Lower arginine levels and higher putrescine levels in BV support conversion of arginine to putrescine. However, lower spermine and higher succinate levels suggest the presence of alternate pathways in BV (FIG. 6, Tables Si, S2). One possible explanation is that putrescine is converted to succinate via y-aminobutyrate (GABA), a novel alternate putrescine utilization pathway that was recently discovered in E. coli (38, 39), wherein putrescine is not converted to spermine. This is also supported by observations of higher levels of N-acetylputrescine in the study, which also leads to the formation of GABA (FIG. 6). Additional pathways may account for the higher levels of succinate in BV.

Carnitine, a product of lysine or methionine degradation, was lower in BV while levels of the precursor, deoxycarnitine, were high. One possible explanation for lower levels of carnitine is conversion to TMA by BV-associated bacteria, a process shown to be mediated by bacteria in the gut (40). TMA is produced from L-carnitine found in meat, and absorbed and converted to trimethylamine oxide (TMAO) in the liver. Production of TMAO can be inhibited by suppressing the intestinal microbiota using antibiotics, demonstrating another role for bacteria in TMA-TMAO metabolism. An alternate explanation for low carnitine in BV is that production is inhibited by lack of ascorbate, which is a necessary cofactor for synthesis.

There were significant alterations in lipid metabolism in BV. Higher levels of 12-HETE and lower levels of its precursor arachidonate in BV observed in both the primary and validation studies (Tables 1, 6) suggests conversion of arachidonate to 12-HETE by BV-associated bacteria. 12-HETE is a signaling eicosanoid that can mediate inflammatory response pathways, is a biomarker for inflammation (41-43) and is a fatty acid that serves membrane structural roles as a component of phospholipids (44). BVAB1 was negatively associated with 12-HETE (−0.028), while other BV-associated bacteria (measured by qPCR), were positively associated with 12-HETE (0.143 to 0.55). Interestingly, 12-HETE has been shown to be correlated with human parturition wherein 12-HETE levels are significantly elevated in laboring women (45). Furthermore, BV is associated with preterm birth (46, 47). Clearly, not all BV-associated bacteria are positively associated with 12-HETE, which suggests that the different sub-types of BV may be correlated with distinct risk factors.

The vaginal epithelium is in a reduced state in BV (48). Nonetheless, there are suggestions of perturbed redox homeostasis in BV, implying oxidative stress in this reduced environment. Reduced glutathione (GSH) to oxidized glutathione (GSSG) ratios are a good estimate of the redox environment; a decrease in GSH to GSSG ratio is suggestive of oxidative stress (49). The GSH/GSSG ratio in women without BV was found to be +3.29, and in BV was 0.23 in the primary study, and similar ratios were noted in the validation study (Table 6). GSH/GSSG ratios are critical in maintaining a reduced environment in the gut (50). All BV-associated bacteria (detected by qPCR) and L. iners were negatively correlated with presence of GSH. L. crispatus and L. jensenii were positively correlated with presence of GSH. In addition, GSH was negatively correlated with the presence of clue cells. Another metabolite indicative of oxidative stress is ascorbate (Vitamin C), a major antioxidant whose levels were significantly lower in BV. A third metabolite that may affect the redox status is spermine, whose concentrations are lower in BV. Spermine is present in semen and has antioxidant properties. Spermine is thought to protect spermatozoa, which contain high levels of polyunsaturated fatty acids that can be susceptible to reactive oxygen species (51). It is unclear why BV is associated with multiple metabolic indictors of oxidative stress when the environment is otherwise considered anaerobic and reduced. There is typically a lack of leukocytes in vaginal fluid from women with BV, so leukocytes are unlikely to contribute to the production of reactive oxygen species.

There were substantial changes in carbohydrate and energy metabolism in BV. One example includes higher levels of N-acetylneuraminate in vaginal fluid from women with BV (Table 1, 6). N acetylneuraminate is the most ubiquitous sialic acid, and is a component of glycoproteins, glycolipids and oligosaccharides (52). A recent study also observed increased quantities of N-acetylneuraminate in vaginal fluid from women with BV (53). There have been many reports of increased activity of sialidases in BV (54-57); sialidases hydrolyze N-acylneuraminic acid residues from oligosaccharides, glycoproteins and glycolipids. A point-of-care diagnostic test for BV that is currently available relies on the measurement of sialidase activity in vaginal fluids (58, 59). Importantly, high sialidase activity in BV has been associated with increased risks for preterm birth (55, 56, 60, 61). Glycoproteins such as mucins are present in mucus, and are reported to create a physical barrier between the host epithelium and bacteria (62, 63); this may be the source of the free N-acetylneuraminate present in vaginal fluid in BV. While little is known about the utilization of this metabolite by vaginal bacteria, a recent study showed that G. vaginalis has the metabolic machinery required for the transport and subsequent breakdown of N-acetylneuraminate as a carbon and energy source (53). Interestingly, N-acetylneuraminate has been shown to play a role in bacterial biofilms (64). Indeed, biofilms may play a role in BV, and G. vaginalis has been shown to be a key member of these biofilms (65-67). Interfering with production or liberation of N-acetylneuraminate in the vagina may be one approach to prevent BV if this metabolite plays a critical role in biofilm formation.

The studies confirm that women with BV had high levels of succinate and low levels of lactate. Consistent with this, BV-associated bacterial concentrations were positively correlated with succinate, while the lactobacilli were negatively correlated. Lactate was also negatively correlated with the presence of an amine odor and elevated pH, two criteria used in the clinical diagnosis of BV FIG. 4, Table 3).

Additional experiments as part of the validation studies were performed to address whether dilution in CVL impacts detection of particular metabolites and found that no metabolite was detected only in swab samples. As expected due to dilution, lower concentrations of metabolites were detected in CVL when compared with swabs (FIG. 10).

Metabolic signatures of BV are distinct and broad, consistent with dramatic changes in vaginal bacterial compositions. There are at least two metabolic sub-types in BV.

The various methods and techniques described above provide a number of ways to carry out the application. Of course, it is to be understood that not necessarily all objectives or advantages described can be achieved in accordance with any particular embodiment described herein. Thus, for example, those skilled in the art will recognize that the methods can be performed in a manner that achieves or optimizes one advantage or group of advantages as taught herein without necessarily achieving other objectives or advantages as taught or suggested herein. A variety of alternatives are mentioned herein. It is to be understood that some preferred embodiments specifically include one, another, or several features, while others specifically exclude one, another, or several features, while still others mitigate a particular feature by inclusion of one, another, or several advantageous features.

Furthermore, the skilled artisan will recognize the applicability of various features from different embodiments. Similarly, the various elements, features and steps discussed above, as well as other known equivalents for each such element, feature or step, can be employed in various combinations by one of ordinary skill in this art to perform methods in accordance with the principles described herein. Among the various elements, features, and steps some will be specifically included and others specifically excluded in diverse embodiments.

Although the application has been disclosed in the context of certain embodiments and examples, it will be understood by those skilled in the art that the embodiments of the application extend beyond the specifically disclosed embodiments to other alternative embodiments and/or uses and modifications and equivalents thereof.

In some embodiments, the numbers expressing quantities of ingredients, properties such as molecular weight, reaction conditions, and so forth, used to describe and claim certain embodiments of the application are to be understood as being modified in some instances by the term “about.” Accordingly, in some embodiments, the numerical parameters set forth in the written description and attached claims are approximations that can vary depending upon the desired properties sought to be obtained by a particular embodiment. In some embodiments, the numerical parameters should be construed in light of the number of reported significant digits and by applying ordinary rounding techniques. Notwithstanding that the numerical ranges and parameters setting forth the broad scope of some embodiments of the application are approximations, the numerical values set forth in the specific examples are reported as precisely as practicable.

In some embodiments, the terms “a” and “an” and “the” and similar references used in the context of describing a particular embodiment of the application (especially in the context of certain of the following claims) can be construed to cover both the singular and the plural. The recitation of ranges of values herein is merely intended to serve as a shorthand method of referring individually to each separate value falling within the range. Unless otherwise indicated herein, each individual value is incorporated into the specification as if it were individually recited herein. All methods described herein can be performed in any suitable order unless otherwise indicated herein or otherwise clearly contradicted by context. The use of any and all examples, or exemplary language (for example, “such as”) provided with respect to certain embodiments herein is intended merely to better illuminate the application and does not pose a limitation on the scope of the application otherwise claimed. No language in the specification should be construed as indicating any non-claimed element essential to the practice of the application.

Preferred embodiments of this application are described herein. Variations on those preferred embodiments will become apparent to those of ordinary skill in the art upon reading the foregoing description. It is contemplated that skilled artisans can employ such variations as appropriate, and the application can be practiced otherwise than specifically described herein. Accordingly, many embodiments of this application include all modifications and equivalents of the subject matter recited in the claims appended hereto as permitted by applicable law. Moreover, any combination of the above-described elements in all possible variations thereof is encompassed by the application unless otherwise indicated herein or otherwise clearly contradicted by context.

All patents, patent applications, publications of patent applications, and other material, such as articles, books, specifications, publications, documents, things, and/or the like, referenced herein are hereby incorporated herein by this reference in their entirety for all purposes, excepting any prosecution file history associated with same, any of same that is inconsistent with or in conflict with the present document, or any of same that may have a limiting affect as to the broadest scope of the claims now or later associated with the present document. By way of example, should there be any inconsistency or conflict between the description, definition, and/or the use of a term associated with any of the incorporated material and that associated with the present document, the description, definition, and/or the use of the term in the present document shall prevail.

In closing, it is to be understood that the embodiments of the application disclosed herein are illustrative of the principles of the embodiments of the invention. Other modifications that can be employed can be within the scope of the application. Thus, by way of example, but not of limitation, alternative configurations of the embodiments of the application can be utilized in accordance with the teachings herein. Accordingly, embodiments of the present application are not limited to that precisely as shown and described.

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The invention claimed is:
 1. A method of diagnosing and treating bacterial vaginosis in a subject, the method comprising: collecting a sample from the subject; assessing a small molecule metabolomic profile by measuring levels of indicative metabolites comprising at least two of: a metabolite associated with the presence of clue cells; a metabolite associated with the presence of amine odors; and a metabolite associated with vaginal discharge; comparing the small molecule metabolomic profile with a diagnostic metabolomic profile; determining that there is a match between the small molecule metabolomic profile and the diagnostic metabolomic profile of at least 50%, the match being indicative of bacterial vaginosis; and administering an antibiotic treatment to the subject.
 2. The method of claim 1 wherein the sample is vaginal fluid or Cervicovaginal lavage fluid (CVL).
 3. The method of claim 1 wherein the method comprises Chromatographic separation and mass spectroscopy.
 4. The method of claim 1 wherein the indicative metabolites comprise one or more metabolites selected from the group consisting of lipids, amino acids, nucleotides, co-factors, vitamins, carbohydrates, energy molecules and redox molecules.
 5. The method of claim 1 wherein the indicative metabolites comprise: one or more fatty acids selected from the group consisting of 13-HODE, 12-HETE, Glycerol-3-P, Arachidonate, Carnitine; one or more nucleotides selected from the group consisting of Oxypurinol, Uracil, Adenosine, AMP, Hypoxanthine, and Urate; or one or more carbohydrates selected from the group consisting of Glyceraldehyde, N-Acetylneuraminate, PEP, F16BP/F26BP/G16BP, Glucoronate, Glucose, Glutamic acid, Lactate, Oxalic Acid, and Sorbitol.
 6. The method of claim 1 wherein the match between the small molecule metabolomic profile and the diagnostic metabolomic profile is at least 80%.
 7. A method of monitoring disease progression and treating bacterial vaginosis in a subject, the method comprising collecting a first sample from the subject at a first time; assessing a first small molecule metabolomic profile by measuring levels of indicative metabolites comprising at least two of: a metabolite associated with the presence of clue cells; a metabolite associated with the presence of amine odors; and a metabolite associated with vaginal discharge; comparing the first small molecule metabolomic profile with a diagnostic metabolomic profile; determining that there is a first match between the first small molecule metabolomic profile and the diagnostic metabolomic profile of at least 50%, the first match being indicative of bacterial vaginosis; collecting a second sample from the subject at a second time that is after the first time; assessing a second small molecule metabolomic profile by measuring levels of the indicative metabolites; comparing the second small molecule metabolomic profile with the diagnostic metabolomic profile; determining that there is a second match between the second small molecule metabolomic profile and the diagnostic metabolomic profile of at least 50%; determining disease progression of the bacterial vaginosis based at least in part on the first and second matches; and administering an antibiotic treatment to the subject.
 8. The method of claim 7 wherein the period of time between the first time and the second time is at least three days.
 9. The method of claim 7 wherein the first sample, the second sample, or both are vaginal fluid or Cervicovaginal lavage fluid (CVL).
 10. The method of claim 1, wherein the metabolite associate with the presence of clue cells is Deoxycarnitine or Pipecolate.
 11. The method of claim 1, wherein the metabolite associated with the presence of amine odors is N-acetylputrescine.
 12. The method of claim 1, wherein the metabolite associated with vaginal discharge is Agmatine or Cadaverine.
 13. The method of claim 1, wherein the indicative metabolites further comprise Tyramine, Tryptamine, 5-aminovalerate, 4-hydroxybutyrate, or a combination thereof.
 14. The method of claim 1, wherein: the metabolite associate with the presence of clue cells is Deoxycarnitine or Pipecolate; the metabolite associated with the presence of amine odors is N-acetylputrescine; and the metabolite associated with vaginal discharge is Agmatine or Cadaverine.
 15. The method of claim 7, wherein the metabolite associate with the presence of clue cells is Deoxycarnitine or Pipecolate.
 16. The method of claim 7, wherein the metabolite associated with the presence of amine odors is N-acetylputrescine.
 17. The method of claim 7, wherein the metabolite associated with vaginal discharge is Agmatine or Cadaverine.
 18. The method of claim 7, wherein the indicative metabolites further comprise Tyramine, Tryptamine, 5-aminovalerate, 4-hydroxybutyrate, or a combination thereof. 